Replacing Ventricular Pacing with His Bundle Pacing: Why is it taking so long?

Introduction: As evidence of harm from ventricular pacing accumulated, the recommendation to replace ventricular pacing with His bundle pacing was first made nearly 50-years ago. Despite having better outcomes, a 2025 consensus statement suggested that His bundle pacing, while more physiological, has unresolvable challenges and therefore niche applicability. This is contrary to our experience. We report our success rates, all-cause mortality and challenges encountered with His bundle pacing in a large, unselected population requiring pacemakers or cardiac resynchronization therapy. Methods: Over a six-year period, 1299 consecutive patients with wide-range of pacing indications including bradycardia, heart block and need for cardiac resynchronization therapy underwent His bundle pacing and were followed for 33±20 months. Results: Using recording systems designed for intracardiac electrograms and in addition, when needed, specialized recording catheters instead of pacing lead, success was achieved 94%. The procedure times were 90±8 minutes. In patients with normal QRS the paced complex remained in normal range. In patients with conduction system disease, abnormal QRS axis and voltage were normalized, and a prolonged ventricular activation time was significantly decreased. Serious complications were rare, and 1-year and 3-year mortality was 7.2% and 13.5%. Conclusion: Our study shows that His bundle pacing is safe and has a high success rate provided specialized methods for intracardiac recording are used instead of systems for routine pacemaker implants. The lower all-cause mortality of His bundle pacing makes it imperative that we adapt available recording methods, in use for electrophysiology studies, to simplify His bundle pacing and increase its adoption.