Background: Left bundle branch area pacing (LBBAP) for cardiac resynchronization therapy (CRT) is an alternative to biventricular pacing (BiVp). Objective: To compare outcomes between LBBAP and BiVp as an initial implant strategy for CRT.Methods: In this prospective multicenter study, first-time CRT implant recipients with LBBAP or BiVp were included. The primary efficacy outcome was a composite of heart failure (HF)-related hospitalization and all-cause mortality. The primary safety outcome were procedure-related complications. Secondary outcomes included postprocedural New York Heart Association (NYHA) functional class, electrocardiographic, and echocardiographic parameters.Results: A total of 371 patients (median follow-up of 340 [IQR: 273] days) were included. The primary efficacy outcome occurred in 24.2% in the LBBAP vs. 42.4% in the BiVp (HR 0.621; 95% CI 0.415, 0.93; p=0.02) group, driven by a reduction in HF-related hospitalizations (22.6% vs. 39.5%; HR 0.607; 95% CI 0.397, 0.927; p=0.02) without significant difference in all-cause mortality (5.5% vs. 11.9%; p=0.19) or in procedure-related complications (9.4% vs. 15.2%; p=0.146). LBBAP resulted in shorter procedural (95 [IQR 55] vs. 129 [IQR 58] minutes, p<0.001) and fluoroscopy times (12 [IQR 13.7] vs. 21.7 [IQR 15.7] minutes, p <0.001); shorter QRS duration (123.7{plus minus}18 vs. 149.3{plus minus}29.1 msec; p<0.001), and higher postprocedural left ventricular ejection fraction (LVEF) (34.1{plus minus}12.5 vs. 31.4{plus minus}10.8 %; p=0.041).Conclusion: LBBAP as an initial CRT strategy resulted in a lower risk of HF-related hospitalizations and all-cause mortality. A reduction in procedural and fluoroscopy times, shorter paced QRS duration, and improvements in LVEF compared to BiVp were observed.