ABC Heart Fail Cardiomyop 2024; 4(3): e20240037

Conduction System Pacing: Redefining Resynchronization Therapy in Heart Failure

Caique M. P. Ternes , André Zimerman

DOI: 10.36660/abchf.20240037i

Abstract

Cardiac resynchronization therapy is a foundational treatment in patients with heart failure with reduced ejection fraction (HFrEF) and left bundle branch block (LBBB). Although resynchronization has traditionally been performed via biventricular pacing, this approach may be limited by a high rate of non-responders and elevated cost. Conduction system pacing, sometimes referred to as “physiologic” pacing, involves direct stimulation of the heart’s intrinsic conduction pathways and has emerged as a promising alternative. Large intercontinental registries have supported the safety of conduction system pacing in different settings, with high procedural success and low complication rates that are comparable to biventricular pacing. Moreover, in small, randomized trials, conduction system pacing has led to similar or greater improvements in left ventricular ejection fraction and QRS duration versus biventricular pacing, potentially at a lower cost. Ongoing cardiovascular outcomes trials are expected to conclusively determine the role of conduction system pacing in the management of patients with HFrEF and LBBB.