Pacemaker lead placement matters: left bundle-branch pacing cut heart-failure events vs standard right-ventricular pacing in JAMA trial

Patients with atrioventricular (AV) block often need a pacemaker that paces the ventricles most of the time. The usual lead position in the right ventricle (RVP) activates the heart in a non-physiological way and can raise heart-failure risk over time. Left bundle-branch area pacing (LBBAP) places the lead so that it uses the heart’s own conduction system. The LEAP-Block trial, published in JAMA on 28 October 2026, compared the two.

The study

• Design: multicentre, randomised, controlled superiority trial at 14 hospitals in China, with blinded endpoint assessment.
• Patients: 499 randomised (482 in the primary analysis), mean age 67, all with AV block, preserved ejection fraction (≥50%), sinus rhythm and expected ventricular pacing above 40%.

Results at 24 months

• Primary composite (all-cause death, heart-failure events or upgrade to biventricular pacing): 2.4% vs 12.5% (P = 0.003); Kaplan–Meier incidence 5.0% vs 13.2% (hazard ratio 0.37).
• The difference was driven mainly by heart-failure events: 3.4% vs 11.3%. Death, upgrades, device complications and pacing-induced cardiomyopathy did not differ significantly.
• Acute procedural success was similar (97.9% vs 99.6%).

Limitations

The trial was not powered to assess each component of the composite separately; follow-up was 24 months; LBBAP used a lumenless lead, so results may not apply to stylet-driven leads; small post-randomisation exclusions may introduce some bias; and all centres were in China, with experienced operators. Which pacing approach suits an individual patient is a decision for their cardiologist.