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This review summarizes current and potential future indications, emerging technologies, and challenges in the implementation of CIEDs in HF. Conventional right ventricular pacing in HF patients is increasingly being replaced by biventricular pacing (BVP) and left bundle branch area pacing (LBBAP), while leadless pacing pacemakers have emerged as an alternative to conventional transvenous systems, offering the potential to reduce lead- and device-related complications. As BVP remains the standard approach for CRT, recent data bestow LBBAP as a promising alternative and integration platform. Newer implantable cardioverter-defibrillator technologies, including subcutaneous and extravascular systems, may reduce lead-related complications while maintaining effective arrhythmia termination and recognition. Advances in atrial fibrillation management, implantable hemodynamic monitoring, and novel pacing indications such as atrioventricular recoupling and personalized pacing in HF with preserved ejection fraction are expanding the therapeutic potential of CIEDs. However, the adoption of these innovations is challenged by limited randomized evidence, procedural complexity, and substantial disparities in access and implementation across healthcare systems. Ongoing clinical trials will help define the role of emerging device technologies and monitoring strategies, while efforts to improve guideline adherence, value-based procurement, and equitable access remain essential to maximize the benefits of CIED therapy in patients with HF.<\/jats:p>\n                  <jats:p>\n                    <jats:bold>Graphical abstract<\/jats:bold>\n                  <\/jats:p>\n                  <jats:p>HF \u2013 heart failure; LVEF \u2013 left ventricular ejection fraction; BVP \u2013 biventricular pacing; CSP \u2013 conduction system pacing; LP \u2013 leadless pacing; LBBAP \u2013 left bundle branch area pacing; RCT \u2013 randomized clinical trial; HFrEF \u2013 heart failure with reduced ejection fraction; CRT \u2013 cardiac resynchronization therapy; LOT-CRT \u2013 left optimized resynchronization therapy; AF \u2013 atrial fibrillation; TV-ICD \u2013 transvenous implantable cardiac defibrillator; SCD \u2013 sudden cardiac death; HFpEF \u2013 heart failure with preserved ejection fraction<\/jats:p>","DOI":"10.1007\/s10741-026-10672-w","type":"journal-article","created":{"date-parts":[[2026,9,1]],"date-time":"2026-09-01T06:50:34Z","timestamp":1788245434000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Cardiac implantable electronic devices in heart failure: needs, challenges, and real-world implementation"],"prefix":"10.1007","volume":"31","author":[{"given":"David","family":"\u017di\u017eek","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Miha","family":"Mrak","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anja Zupan","family":"Me\u017enar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maja","family":"Ivanovski","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tadej","family":"\u017dlahti\u010d","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher F.","family":"Barrientos","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andrew P.","family":"Ambrosy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zlatko","family":"Fras","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mauro","family":"Biffi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mitja","family":"Lainscak","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,9,1]]},"reference":[{"key":"10672_CR1","doi-asserted-by":"publisher","first-page":"442","DOI":"10.1056\/nejmra2308353","volume":"390","author":"SM Al-Khatib","year":"2024","unstructured":"Al-Khatib SM (2024) Cardiac implantable electronic devices. 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