{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,28]],"date-time":"2026-03-28T19:44:43Z","timestamp":1774727083998,"version":"3.50.1"},"reference-count":52,"publisher":"MDPI AG","issue":"5","license":[{"start":{"date-parts":[[2024,5,2]],"date-time":"2024-05-02T00:00:00Z","timestamp":1714608000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCDD"],"abstract":"<jats:p>Cardiac resynchronization therapy (CRT) significantly improves clinical outcomes in patients with ventricular systolic dysfunction and dyssynchrony. Biventricular pacing (BVP) has a class IA recommendation for patients with symptomatic heart failure with reduced ejection fraction (HFrEF) and left bundle branch block (LBBB). However, approximately 30% of patients have a poor therapeutic response and do not achieve real clinical benefit. Pre-implant imaging, together with tailored programming and dedicated device algorithms, have been proposed as possible tools to improve success rate but have shown inconsistent results. Over the last few years, conduction system pacing (CSP) is becoming a real and attractive alternative to standard BVP as it can restore narrow QRS in patients with bundle branch block (BBB) by stimulating and recruiting the cardiac conduction system, thus ensuring true resynchronization. It includes His bundle pacing (HBP) and left bundle branch area pacing (LBBAP). Preliminary data coming from small single-center experiences are very promising and have laid the basis for currently ongoing randomized controlled trials comparing CSP with BVP. The purpose of this review is to delve into the emerging role of CSP as an alternative method of achieving CRT. After framing CSP in a historical perspective, the pathophysiological rationale and available clinical evidence will be examined, and crucial technical aspects will be discussed. Finally, evidence gaps and future perspectives on CSP as a technique of choice to deliver CRT will be summarized.<\/jats:p>","DOI":"10.3390\/jcdd11050144","type":"journal-article","created":{"date-parts":[[2024,5,2]],"date-time":"2024-05-02T07:04:14Z","timestamp":1714633454000},"page":"144","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Is Conduction System Pacing a Valuable Alternative to Biventricular Pacing for Cardiac Resynchronization Therapy?"],"prefix":"10.3390","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8491-152X","authenticated-orcid":false,"given":"Davide","family":"Castagno","sequence":"first","affiliation":[{"name":"Division of Cardiology, Department of Medical Sciences, University of Turin, 10126 Turin, Italy"},{"name":"Division of Cardiology, Cardiovascular and Thoracic Department, \u201cCitta della Salute e della Scienza\u201d Hospital, 10126 Turin, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2673-3918","authenticated-orcid":false,"given":"Francesco","family":"Zanon","sequence":"additional","affiliation":[{"name":"Santa Maria della Misericordia Hospital, Arrhythmia and Electrophysiology Unit, 45100 Rovigo, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Gianni","family":"Pastore","sequence":"additional","affiliation":[{"name":"Santa Maria della Misericordia Hospital, Arrhythmia and Electrophysiology Unit, 45100 Rovigo, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4940-0876","authenticated-orcid":false,"given":"Gaetano Maria","family":"De Ferrari","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Medical Sciences, University of Turin, 10126 Turin, Italy"},{"name":"Division of Cardiology, Cardiovascular and Thoracic Department, \u201cCitta della Salute e della Scienza\u201d Hospital, 10126 Turin, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5854-9782","authenticated-orcid":false,"given":"Lina","family":"Marcantoni","sequence":"additional","affiliation":[{"name":"Santa Maria della Misericordia Hospital, Arrhythmia and Electrophysiology Unit, 45100 Rovigo, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2024,5,2]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"3427","DOI":"10.1093\/eurheartj\/ehab364","article-title":"2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy","volume":"42","author":"Glikson","year":"2021","journal-title":"Eur. Heart J."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"e17","DOI":"10.1016\/j.hrthm.2023.03.1538","article-title":"2023 HRS\/APHRS\/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure","volume":"20","author":"Chung","year":"2023","journal-title":"Heart Rhythm."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"889","DOI":"10.1136\/heartjnl-2020-317171","article-title":"Advances in cardiac resynchronization therapy: Review of indications and delivery options","volume":"108","author":"Keene","year":"2022","journal-title":"Heart"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1435","DOI":"10.1093\/cvr\/cvy182","article-title":"Cardiac resynchronization is pro-arrhythmic in the absence of reverse ventricular remodelling: A systematic review and meta-analysis","volume":"114","author":"Deif","year":"2018","journal-title":"Cardiovasc. Res."},{"key":"ref_5","first-page":"1463","article-title":"Avoiding non-responders to cardiac resynchronization therapy: A practical guide","volume":"38","author":"Daubert","year":"2017","journal-title":"Eur. Heart J."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"682","DOI":"10.1093\/europace\/euac201","article-title":"Conduction system pacing in everyday clinical practice: EHRA physician survey","volume":"25","author":"Kircanski","year":"2023","journal-title":"Europace."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1329","DOI":"10.1056\/NEJMoa0906431","article-title":"Cardiac-resynchronization therapy for the prevention of heart-failure events","volume":"361","author":"Moss","year":"2009","journal-title":"N. Engl. J. Med."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1499","DOI":"10.1093\/europace\/eut049","article-title":"True complete left bundle branch block morphology strongly predicts good response to cardiac resynchronization therapy","volume":"15","author":"Tian","year":"2013","journal-title":"Europace"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1694","DOI":"10.1056\/NEJMoa1401426","article-title":"Survival with cardiac-resynchronization therapy in mild heart failure","volume":"370","author":"Goldenberg","year":"2014","journal-title":"N. Engl. J. Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1161\/01.CIR.44.1.9","article-title":"Fine structure of the His bundle","volume":"44","author":"James","year":"1971","journal-title":"Circulation"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"473","DOI":"10.1161\/01.CIR.57.3.473","article-title":"Normalization of bundle branch block patterns by distal His bundle pacing. Clinical and experimental evidence of longitudinal dissociation in the pathologic his bundle","volume":"57","author":"Schonfield","year":"1978","journal-title":"Circulation"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"996","DOI":"10.1161\/01.CIR.56.6.996","article-title":"Longitudinal dissociation in the His bundle. Bundle branch block due to asynchronous conduction within the His bundle in man","volume":"56","author":"Narula","year":"1977","journal-title":"Circulation"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"889","DOI":"10.1161\/CIRCEP.111.967505","article-title":"Benefits of endocardial and multisite pacing are dependent on the type of left ventricular electric activation pattern and presence of ischemic heart disease: Insights from electroanatomic mapping","volume":"5","author":"Ginks","year":"2012","journal-title":"Circ. Arrhythm Electrophysiol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1876","DOI":"10.1161\/CIRCULATIONAHA.118.038648","article-title":"Intracardiac Delineation of Septal Conduction in Left Bundle-Branch Block Patterns","volume":"139","author":"Upadhyay","year":"2019","journal-title":"Circulation"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e12563","DOI":"10.1111\/anec.12563","article-title":"Comparison of four LBBB definitions for predicting mortality in patients receiving cardiac resynchronization therapy","volume":"23","author":"Kukla","year":"2018","journal-title":"Ann. Noninvasive Electrocardiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1016\/j.ijcard.2018.07.060","article-title":"The definition of left bundle branch block influences the response to cardiac resynchronization therapy","volume":"269","author":"Caputo","year":"2018","journal-title":"Int. J. Cardiol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"3112","DOI":"10.1016\/j.jacc.2018.09.073","article-title":"His Resynchronization Versus Biventricular Pacing in Patients With Heart Failure and Left Bundle Branch Block","volume":"72","author":"Arnold","year":"2018","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Baroni, M., Preda, A., Varrenti, M., Vargiu, S., Carbonaro, M., Giordano, F., Gigli, L., and Mazzone, P. (2023). Left Bundle Branch Area Pacing over His Bundle Pacing: How Far Have We Come?. J. Clin. Med., 12.","DOI":"10.3390\/jcm12093251"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1205","DOI":"10.1016\/j.jacc.2022.07.019","article-title":"Randomized Trial of Left Bundle Branch vs Biventricular Pacing for Cardiac Resynchronization Therapy","volume":"80","author":"Wang","year":"2022","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"e003793","DOI":"10.1161\/CIRCEP.115.003793","article-title":"Simultaneous His Bundle and Left Ventricular Pacing for Optimal Cardiac Resynchronization Therapy Delivery: Acute Hemodynamic Assessment by Pressure-Volume Loops","volume":"9","author":"Padeletti","year":"2016","journal-title":"Circ. Arrhythm Electrophysiol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"347","DOI":"10.1016\/j.jacc.2019.11.040","article-title":"Short-Term Hemodynamic and Electrophysiological Effects of Cardiac Resynchronization by Left Ventricular Septal Pacing","volume":"75","author":"Salden","year":"2020","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"881","DOI":"10.1016\/j.jacep.2020.11.029","article-title":"His-Optimized Cardiac Resynchronization Therapy with Ventricular Fusion Pacing for Electrical Resynchronization in Heart Failure","volume":"7","author":"Zweerink","year":"2021","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"e011181","DOI":"10.1161\/CIRCEP.122.011181","article-title":"Left Bundle Branch Pacing Versus Biventricular Pacing for Acute Cardiac Resynchronization in Patients with Heart Failure","volume":"15","author":"Liang","year":"2022","journal-title":"Circ. Arrhythm Electrophysiol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1431","DOI":"10.1016\/j.jacep.2022.08.001","article-title":"Conduction System Pacing vs Biventricular Pacing in Heart Failure and Wide QRS Patients: LEVEL-AT Trial","volume":"8","author":"Garre","year":"2022","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1060","DOI":"10.1093\/europace\/euac245","article-title":"Comparison of methods for delivering cardiac resynchronization therapy: An acute electrical and haemodynamic within-patient comparison of left bundle branch area, His bundle, and biventricular pacing","volume":"25","author":"Ali","year":"2023","journal-title":"Europace"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"869","DOI":"10.1161\/01.CIR.101.8.869","article-title":"Permanent, direct His-bundle pacing: A novel approach to cardiac pacing in patients with normal His-Purkinje activation","volume":"101","author":"Deshmukh","year":"2000","journal-title":"Circulation"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1093\/europace\/eus228","article-title":"Ventricular resynchronization therapy by direct His-bundle pacing using an internal cardioverter defibrillator","volume":"15","year":"2013","journal-title":"Europace"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1548","DOI":"10.1016\/j.hrthm.2015.03.048","article-title":"His-bundle pacing versus biventricular pacing in cardiac resynchronization therapy patients: A crossover design comparison","volume":"12","author":"Lustgarten","year":"2015","journal-title":"Heart Rhythm"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"769","DOI":"10.1016\/j.hlc.2011.05.617","article-title":"Electrical and mechanical cardiac resynchronisation by novel direct his-bundle pacing in a heart failure patient","volume":"20","author":"Manovel","year":"2011","journal-title":"Heart Lung Circ."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"419","DOI":"10.1016\/j.hrthm.2023.12.009","article-title":"Left bundle branch pacing lead for sensing ventricular arrhythmias in implantable cardioverter-defibrillator: A pilot study (LBBP-ICD study)","volume":"21","author":"Ponnusamy","year":"2023","journal-title":"Heart Rhythm"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"100104","DOI":"10.1016\/j.hsr.2023.100104","article-title":"Conduction system pacing vs. biventricular pacing for cardiac resynchronization therapy in heart failure with reduced ejection fraction: An updated systematic review and meta-analysis","volume":"8","author":"Shresthaa","year":"2023","journal-title":"Health Sci. Rev."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"905","DOI":"10.1007\/s10840-022-01342-6","article-title":"Dual-chamber ICD for left bundle branch area pacing: The cardiac resynchronization and arrhythmia sensing via the left bundle (cross-left) pilot study","volume":"66","author":"Clementy","year":"2023","journal-title":"J. Interv. Card. Electrophysiol."},{"key":"ref_33","first-page":"72","article-title":"Lead-to-lead interaction leading to left bundle branch area pacing lead failure","volume":"9","author":"Mahajan","year":"2022","journal-title":"Heart Rhythm Case Rep."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"820","DOI":"10.1016\/j.hroo.2023.11.009","article-title":"Mechanisms of damage related to ICD and pacemaker lead interaction","volume":"4","author":"Pokharel","year":"2023","journal-title":"Heat Rhythm. O2"},{"key":"ref_35","first-page":"72","article-title":"Interaction between left bundle branch area pacing and defibrillator lead: A case report","volume":"10","author":"Francois","year":"2023","journal-title":"Heart Rhythm Case Rep."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"157","DOI":"10.1016\/j.jacc.2019.04.026","article-title":"His Corrective Pacing or Biventricular Pacing for Cardiac Resynchronization in Heart Failure","volume":"74","author":"Upadhyay","year":"2019","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"620","DOI":"10.1016\/j.jacep.2023.01.006","article-title":"Left Bundle Branch Area Defibrillator (LBBAD): A First-in-Human Feasibility Study","volume":"9","author":"Huybrechts","year":"2023","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"1422","DOI":"10.1016\/j.jacep.2021.04.003","article-title":"A Randomized Trial of His Pacing Versus Biventricular Pacing in Symptomatic HF Patients With Left Bundle Branch Block (His-Alternative)","volume":"7","author":"Vinther","year":"2021","journal-title":"JACC Clin. Electrophysiol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"4161","DOI":"10.1093\/eurheartj\/ehac445","article-title":"Left bundle branch area pacing outcomes: The multicentre European MELOS study","volume":"43","author":"Cano","year":"2022","journal-title":"Eur. Heart J."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"760","DOI":"10.1111\/jce.15853","article-title":"Predictors of procedural failure of left bundle branch pacing in scarred left ventricle","volume":"34","author":"Ponnusamy","year":"2023","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1718","DOI":"10.1111\/jce.15976","article-title":"Clinical outcomes of conduction system pacing versus biventricular pacing for cardiac resynchronization therapy: A systematic review and meta-analysis","volume":"34","author":"Kim","year":"2023","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"432","DOI":"10.1111\/pace.14700","article-title":"Left bundle branch pacing versus biventricular pacing for cardiac resynchronization therapy: A systematic review and meta-analysis","volume":"46","author":"Parlavecchio","year":"2023","journal-title":"Pacing Clin. Electrophysiol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"757","DOI":"10.1093\/europace\/euaa350","article-title":"His bundle pacing capture threshold stability during long-term follow-up and correlation with lead slack","volume":"23","author":"Beer","year":"2021","journal-title":"Europace"},{"key":"ref_44","doi-asserted-by":"crossref","unstructured":"\u00d6zpak, E., Van Heuverswyn, F., Timmermans, F., and De Pooter, J. (2024). Lead performance of stylet-driven leads in left bundle branch area pacing: Results from a large single-center cohort and insights from in vitro bench testing. Heart Rhythm.","DOI":"10.1016\/j.hrthm.2024.01.049"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"490","DOI":"10.1016\/j.hrthm.2023.12.023","article-title":"Late distal conductor fracture of the lumenless pacing lead after left bundle branch area pacing","volume":"21","author":"Rangaswamy","year":"2024","journal-title":"Heart Rhythm."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"707148","DOI":"10.3389\/fcvm.2022.707148","article-title":"Clinical Outcomes Associated With His-Purkinje System Pacing vs. Biventricular Pacing, in Cardiac Resynchronization Therapy: A Meta-Analysis","volume":"9","author":"Gui","year":"2022","journal-title":"Front. Cardiovasc. Med."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1178","DOI":"10.1016\/j.hrthm.2023.05.010","article-title":"Improved outcomes of conduction system pacing in heart failure with reduced ejection fraction: A systematic review and meta-analysis","volume":"20","author":"Gin","year":"2023","journal-title":"Heart Rhythm."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"274","DOI":"10.1002\/ejhf.2736","article-title":"Effects of haemodynamically atrio-ventricular optimized His bundle pacing on heart failure symptoms and exercise capacity: The His Optimized Pacing Evaluated for Heart Failure (HOPE-HF) randomized, double-blind, cross-over trial","volume":"25","author":"Whinnett","year":"2023","journal-title":"Eur. J. Heart Fail."},{"key":"ref_49","first-page":"2628","article-title":"His-Purkinje Conduction System Pacing Optimized Trial of Cardiac Resynchronization Therapy vs Biventricular Pacing: HOT-CRT Clinical Trial","volume":"9","author":"Vijayaraman","year":"2023","journal-title":"JACC-EP"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"655","DOI":"10.1093\/eurheartj\/ehz467","article-title":"2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC)","volume":"41","author":"Brugada","year":"2020","journal-title":"Eur. Heart J."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"1208","DOI":"10.1093\/europace\/euad043","article-title":"EHRA clinical consensus statement on conduction system pacing implantation: Endorsed by the Asia Pacific Heart Rhythm Society (APHRS), Canadian Heart Rhythm Society (CHRS), and Latin American Heart Rhythm Society (LAHRS)","volume":"25","author":"Burri","year":"2023","journal-title":"Europace"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"1236369","DOI":"10.3389\/fcvm.2023.1236369","article-title":"The weakest point of cardiac resynchronization therapy: New technologies facing old terminology","volume":"10","author":"Marcantoni","year":"2023","journal-title":"Front. Cardiovasc. Med."}],"container-title":["Journal of Cardiovascular Development and Disease"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2308-3425\/11\/5\/144\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T14:38:53Z","timestamp":1760107133000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2308-3425\/11\/5\/144"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,5,2]]},"references-count":52,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2024,5]]}},"alternative-id":["jcdd11050144"],"URL":"https:\/\/doi.org\/10.3390\/jcdd11050144","relation":{},"ISSN":["2308-3425"],"issn-type":[{"value":"2308-3425","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,5,2]]}}}