AbstractBackgroundConduction system pacing (CSP), including His‐bundle pacing (HBP) and left bundle branch area pacing (LBBAP), have been proposed as alternatives to biventricular pacing (BVP) in patients scheduled for ablate and pace (A&P) strategy. The aim of this study was to compare the clinical outcomes, including the rate and nature of device‐related complications, between BVP and CSP in a cohort of patients undergoing A&P.MethodsProspective, multicenter, observational study, enrolling consecutive patients undergoing A&P. The risk of device‐related complications and of heart failure (HF) hospitalization was prospectively assessed.ResultsA total of 373 patients (75.3 ± 8.7 years, 53.9% male, 68.9% with NYHA class ≥III) were enrolled: 263 with BVP, 68 with HBP, and 42 with LBBAP. Baseline characteristics of the three groups were similar. Compared to BVP and HBP, LBBAP was associated with the shortest mean procedural and fluoroscopy times and with the lowest acute capture thresholds (all p < .05). At 12‐month follow‐up LBBAP maintained the lowest capture thresholds and showed the longest estimated residual battery longevity (all p < .05). At 12‐months follow‐up the three study groups showed a similar risk of device‐related complications (5.7%, 4.4%, and 2.4% for BVP, HBP, and LBBAP, respectively; p = .650), and of HF hospitalization (2.7%, 1.5%, and 2.4% for BVP, HBP, and LBBAP, respectively; p = .850).ConclusionsIn the setting of A&P, CSP is a feasible pacing modality, with a midterm safety profile comparable to BVP. LBBAP offers the advantage of reducing procedural times and obtaining lower and stable capture thresholds, with a positive impact on the device longevity.