Abstract Background Left bundle branch area pacing (LBBAP) and endocardial resynchronization (Endo‐CRT) are alternatives to biventricular pacing for cardiac resynchronization therapy (CRT). Objective To compare the outcomes of LBBAP versus Endo‐CRT using conventional pacing leads. Methods Patients with heart failure (HF) undergoing CRT with LBBAP or Endo‐CRT were included. The primary efficacy outcome was a composite of HF‐related hospitalization and all‐cause mortality. The primary safety outcome was any procedure‐related complication. Secondary outcomes included procedural characteristics, electrocardiographic, and echocardiographic parameters. Results A total of 223 patients (LBBAP n = 197, Endo‐CRT n = 26; mean age 69 ± 10.3 years, 32.3% female) were included. Patients in the LBBAP group had lower NYHA class, shorter preprocedural QRS durations (161 [142–183] vs. 180 [170–203] msec, p < .001), and a lower preprocedural spironolactone use (57.4% vs. 84.6%, p = .009) than patients in the Endo‐CRT group. Fluoroscopy time was significantly shorter in patients undergoing LBBAP (11.4 [7.2–20] vs. 23 [14.2–34.5] min; p < .001). There was no significant difference in the primary efficacy outcome between both groups (Cox proportional HR 1.21, 95% CI 0.635–2.31; p = .56). During follow‐up, patients undergoing LBBAP had a lower incidence of stroke than patients in the Endo‐CRT group (0% vs. 11.5%, p = .001). Postprocedural LVEF (35% [25–45] vs. 40% [20–55]; p = .307) and change in LVEF (7% [0–20] vs. 11% [2–18]; p = .384) were similar between the LBBAP and the Endo‐CRT groups, respectively. Conclusion LBBAP and Endo‐CRT using conventional leads are associated with similar mortality and HF‐related hospitalization, as well as improvements in LVEF. Endo‐CRT is associated with longer fluoroscopy times and a higher risk of stroke.