A new heart failure pacing option may reduce repeat surgeries and shorten implant procedures

Left bundle branch area pacing is an effective and practical strategy for cardiac resynchronization, according to a late-breaking science presentation at EHRA 2026, the annual congress of the European Heart Rhythm Association (EHRA), a branch of the European Society of Cardiology (ESC).

Cardiac resynchronization therapy (CRT) involves implanting a pacemaker device to help the chambers of the heart pump simultaneously. CRT is used in certain patients with heart failure who remain symptomatic despite guideline-recommended medical therapy and have electrical dyssynchrony. Specifically, it is a treatment option for patients with heart failure and reduced left ventricular ejection fraction (LVEF) who exhibit a dyssynchronous ECG pattern called left bundle branch block.

“CRT with biventricular pacing is a well-established standard approach, but up to one-third of patients do not respond,” explained study presenter, Professor Jean-Benoît le Polain de Waroux from AZ Sint-Jan Hospital, Bruges, Belgium. “Left bundle branch area pacing (LBBAP) has emerged as a more physiological approach to restore synchrony; however, there is a lack of data from head-to-head randomized trials. The LECART trial was designed to compare LBBAP with biventricular pacing and uniquely incorporated the clinically meaningful endpoints of device-related complications requiring surgical re-interventions and failure to deliver resynchronization.”

The prospective, randomized LECART trial was conducted at 11 high-volume centers in Belgium. Patients were eligible for inclusion if they had heart failure of NYHA functional class II−IV, LVEF <40%, left bundle branch block and an indication for CRT according to current ESC Guidelines. Patients were randomized 1:1 to LBBAP or biventricular pacing.

The primary outcome, assessed over the first year, was a four-component composite: death from any cause, heart failure hospitalization, any device-related complication requiring a surgical re-intervention, or failure to deliver the assigned resynchronization therapy efficiently. All events were reviewed by an independent blinded adjudication committee.

The 168 randomized patients had a mean age of 69 years, with 33% being female. Most patients (67%) had NYHA class II heart failure, and 77.5% were receiving at least three out of the four ESC Guidelines-recommended pillars of heart failure medication.

Over the first year after device implantation, the incidence of the primary outcome was 25% in the biventricular pacing group and 13% in the LBBAP group (hazard ratio 2.14; 95% confidence interval [CI] 1.01 to 4.51; p=0.039). This difference was predominantly driven by a higher incidence of device-related complications with biventricular pacing vs. LBBAP (15% vs. 1%; odds ratio 6.76; 95% CI 1.48 to 31.25; p=0.006), with no significant difference observed for death, heart failure hospitalization and implant failure.

Procedure time was significantly longer with biventricular pacing vs. LBBAP (90 minutes vs. 76 minutes; p=0.005), with similar functional improvement in both groups.

Professor le Polain de Waroux concluded, “This is the first randomized trial to demonstrate that LBBAP provides effective cardiac synchronization while decreasing the need for surgical re-intervention. The reduction in complications plus shorter procedure times with LBBAP are important both for patients and for the health care system as a whole.”