Left Bundle-Branch Area Pacing vs Right Ventricular Pacing for Atrioventricular Block and Preserved Left Ventricular Function: The LEAP-Block Randomized Clinical Trial

For patients with atrioventricular block requiring high-burden ventricular pacing, the optimal pacing strategy to reduce heart failure (HF) and all-cause mortality remains uncertain.

By Li, Wang, Zhang +27JAMAOct 28, 2026

Score█████░░░░░5.3

Key numbers

50% or greater requiring ventricular
40% were randomized
46% female

VerdictA leading story on any desk.

Read the original

Abstract

Importance For patients with atrioventricular block requiring high-burden ventricular pacing, the optimal pacing strategy to reduce heart failure (HF) and all-cause mortality remains uncertain. Robust comparative evidence on the clinical outcomes of left bundle-branch area pacing (LBBAP) vs right ventricular pacing (RVP) in this population is needed. Objective To compare 24-month clinical outcomes of LBBAP vs RVP in patients with atrioventricular block and preserved left ventricular ejection fraction (LVEF; ≥50%). Design, setting, and participants The LEAP-Block study was a prospective, multicenter, randomized, controlled, superiority trial conducted across 14 Chinese hospitals from January 2021 to August 2025, with last follow-up on June 3, 2025. Of 551 patients with LVEF 50% or greater requiring ventricular pacing who underwent eligibility assessment, 499 with anticipated ventricular pacing greater than 40% were randomized. Interventions Patients were randomized in a 1:1 ratio to LBBAP (n = 249) or RVP (n = 250). Main outcomes and measures The primary end point was a composite of all-cause death, HF events, or upgrade to biventricular pacing at 24 months. Secondary end points included pacing-induced cardiomyopathy and device-related complications. Results The primary analysis included 482 patients (LBBAP, n = 242; RVP, n = 240; mean age, 67 years; 46% female). Acute procedure success was comparable between the 2 groups (LBBAP, 237/242 [97.9%] vs RVP, 239/240 [99.6%]; P = .22), with left bundle-branch capture confirmed in 188 of 236 patients (79.7%). LBBAP significantly reduced the primary end point vs RVP (2.4% vs 12.5%, respectively; absolute risk difference, -10.1% [95% CI, -16.8% to -3.4%]; P = .003). Among secondary outcomes, the LBBAP group had fewer HF events (3.4% vs 11.3%; -7.9% [95% CI, -13.0% to -2.8%]). No significant differences were observed in all-cause death, biventricular pacing upgrade, device-related complications, or pacing-induced cardiomyopathy. The 24-month Kaplan-Meier estimated cumulative incidence of the primary end point was 5.0% for LBBAP vs 13.2% for RVP (hazard ratio, 0.37 [95% CI, 0.19 to 0.73]; P = .004). LBBAP superiority was consistent across all prespecified subgroups. Conclusions and relevance Among patients with atrioventricular block and preserved LVEF requiring high-burden ventricular pacing, LBBAP was superior to RVP in reducing the risk of the composite end point of all-cause death, HF events, or upgrade to biventricular pacing at 24 months. Trial registration ClinicalTrials.gov Identifier: NCT04730921.

Xiaofei Li, Haixiong Wang, Wenjuan Zhang, Ling You, Chunguang Qiu, Fengpeng Jia, Zhimin Liu, Xiaoming Li, Ruxing Wang, Taibo Chen, Wenhua Lin, Ming Ren, Kang'an Cheng, Hui Peng, Jing Zhou, Haitao Yang, Yongquan Wu, Haojie Zhu, Zhao Wang, Chen He, Zhijun Sun, Songyun Chu, Yang Wang, Wei Li, Yanyan Zhao, Michael R Gold, Kenneth A Ellenbogen, Yan Yao, Xiaohan Fan, LEAP-Block Investigators

The editor's rubric

Heuristic review

Leverage2 / 5: Reusable within one subfield (a technique, dataset, or protocol a few groups will adopt).; 10% of this desk’s rubric
Magnitude5 / 5: A discontinuity (AlexNet cutting ImageNet top-5 error from 26% to 15%, AlphaFold 2 at median GDT 92, 95% vaccine efficacy).; 20% of this desk’s rubric
Evidence4 / 5: Strong: large scale, preregistered, independently replicated, or a well-powered randomized trial.; 32% of this desk’s rubric
Novelty3 / 5: A genuinely new approach to an open problem.; 8% of this desk’s rubric
Trajectory2 / 5: Some room to improve with obvious engineering.; 5% of this desk’s rubric
Stakes3 / 5: Meaningful benefit to many people within a few years.; 25% of this desk’s rubric

Dimension	Level	Weight	What that level means
Leverage	██░░░2/5	10%	Reusable within one subfield (a technique, dataset, or protocol a few groups will adopt).
Magnitude	█████5/5	20%	A discontinuity (AlexNet cutting ImageNet top-5 error from 26% to 15%, AlphaFold 2 at median GDT 92, 95% vaccine efficacy).
Evidence	████░4/5	32%	Strong: large scale, preregistered, independently replicated, or a well-powered randomized trial.
Novelty	███░░3/5	8%	A genuinely new approach to an open problem.
Trajectory	██░░░2/5	5%	Some room to improve with obvious engineering.
Stakes	███░░3/5	25%	Meaningful benefit to many people within a few years.

Editor’s rationale

Heuristic triage from title and abstract text only, not a reading of the paper. Cues found: gains (relative gain, versus baseline, efficacy); novelty (open problem); design (randomized, registered, multicenter); verification (confidence interval, p-value, independent replication); stakes (mortality, major disease).

How the score was computed

rank-2026-10-18

Score█████░░░░░5.3

Score = 10 × (80% × adjusted merit / 10 + 10% × attention + 10% × freshness)

Desks place stronger verdicts first, then use this score to order work within the same verdict.

Merit: 7.1 / 10; Weighted rubric, evidence-gated.
Adjusted merit: 5.6 / 10; Shrunk toward the desk prior by editor confidence (50%).
Attention: 0%; Citations, upvotes, points, mentions.
Freshness: 85%; Half-life decay since publication.

Citations0 (reference 20, via openalex, Oct 30, 2026, 06:17 UTC)

The record

Reviewed by heuristic-v10 on Oct 30, 2026, 06:17 UTC. Paper type: clinical.
Categories: Journal Article
LEAD, No.1 in the Front page edition of October 30, 2026.
TOP, No.2 in the Medicine edition of October 30, 2026.