Real-world adoption of left bundle branch area pacing: Insights from the Conduction-System pacing Italian Network Group (C-SING)

Background and objective: Left bundle branch area pacing (LBBAP) is increasingly used for treating bradycardia and heart failure. However, real-world data are limited. The Conduction-System Pacing Italian Network Group (C-SING) collected prospective data on LBBAP procedures in a nationwide context. Methods: Observational data from 28 Italian sites were analysed for consecutive LBBAP procedures, comparing outcomes based on operator experience levels. Results: From January 2022 to December 2023, 1250 patients (median age 78, 66.2 % male) underwent LBBAP attempt. Most frequent indications were atrioventricular block (40.8 %) and heart failure (25.6 %). Successful lead implantation was achieved in 1207 procedures (96.6 %), with a median fluoroscopy time of 6.2 min. Significant QRS duration reduction was observed in patients with interventricular conduction delay (144 ms to 120 ms, p < 0.001). Compared to low-experience operators (0–10 previous cases), high-experience operators (>50 cases) had significantly better outcomes, with reduced fluoroscopy time (5.9 min versus 9.0 min, p = 0.005) and an 86 % lower risk of lead implantation failure (adjusted odds ratio 0.14, p = 0.002). Periprocedural complications occurred in 6.2 % of patients, unaffected by operator experience. Follow-up data for 794 patients over a median of 93 days showed stable LBBAP pacing parameters and a 1.3 % loss of LBBAP capture. Conclusions: LBBAP is routinely adopted for bradycardia and heart failure indication, with high success and acceptable complication rates, even when performed by less experienced operators. However, procedure outcomes improved significantly as operators gained experience with at least 50 prior cases. Electrical parameters remained stable with a low rate of LBBAP loss during short-term follow-up.