BACKGROUND Left bundle branch area pacing (LBBAP), a new pacing approach, lacks adequate evaluation. OBJECTIVE To assess the feasibility, safety, and acute effect of permanent LBBAP in patients with atrioventricular block (AVB). METHODS A total of 33 AVB patients with indications for ventricular pacing were recruited. Electrocardiograms, pacing parameters, echocardiographic measurements, and complications associated with LBBAP were evaluated perioperatively and at 3-month follow-up. Successful LBBAP was defined as a paced QRS morphology of right bundle branch block pattern in lead V 1 and QRS duration (QRSd) less than 130 ms. RESULTS LBBAP was successfully performed in 90.9% (30/33) of patients (mean age: 55.1 6 18.5 years; 66.7% male). The mean capture threshold was similar during the procedure (0.76 6 0.26 V at 0.4 ms) and at the 3-month follow-up (0.64 6 0.20 V at 0.4 ms). The paced QRSd was 112.8 6 10.9 ms during the procedure and 116.8 6 10.4 ms at the 3-month follow-up. Baseline left or right bundle branch block was corrected (intrinsic QRSd 153.3 6 27.8 ms vs paced QRSd 122.2 6 9.9 ms) with a success rate of 68.7% (11/16). One ventricular septal lead perforation occurred soon after the procedure with characteristics of pacing failure, and lead revision was successful. Cardiac function and left ventricular synchronization by 2-dimensional echocardiographic strain imaging at the 3month follow-up slightly improved compared with that at baseline.

Aims This multicentre observational study aimed to prospectively assess the efficacy of left bundle branch area pacing (LBBAP) in heart failure patients with left bundle branch block (LBBB) and compare the 6-month outcomes between LBBAP and biventricular pacing (BVP). Methods and results Consecutive patients with LBBB and left ventricular ejection fraction (LVEF) ≤ 35% were prospectively recruited if they had undergone LBBAP as a primary or rescue strategy from three separate centres from March to December 2018. Patients who received BVP in 2018 were retrospectively selected by using 2 to 1 propensity score matching to minimize bias. Implant characteristics and echocardiographic parameters were assessed during the 6-month follow-up. LBBAP procedure succeeded in 81.1% (30/37) of patients, with selective LBBAP in 10 patients, and 3 of 20 patients combined non-selective LBBAP and LV lead pacing for further QRS narrowing. LBBAP resulted in significant QRS narrowing (from 178.2 ± 18.8 to 121.8 ± 10.8 ms, P < 0.001, paced QRS duration ≤ 130 ms in 27 patients) and improved LVEF (from 28.8 ± 4.5% to 44.3 ± 8.7%, P < 0.001) during the 6-month follow-up. The comparison between 27 patients with LBBAP alone and 54 of 130 matching patients with BVP showed that LBBAP delivered a greater reduction in the QRSd (58.0 vs. 12.5 ms, P < 0.001), a greater increase in LVEF (15.6% vs. 7.0%, P < 0.001), and greater echocardiographic (88.9% vs. 66.7%, P = 0.035) and super response (44.4% vs. 16.7%, P = 0.007) to cardiac resynchronization therapy. Conclusions LBBAP could deliver cardiac resynchronization therapy in most patients with heart failure and LBBB, and might be a promising alternative resynchronization approach to BVP.

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