His-bundle pacing in a patient with dextrocardia, severe systolic dysfunction, and complete atrioventricular block

Key Teaching Points•Cardiac resynchronization therapy (CRT) in patients with complex cardiomyopathy is an added difficulty for the optimal placement of the left ventricle electrode in a coronary sinus vein. The alternative in these cases is usually epicardial implantation in most centers.•His-bundle pacing (HBP) has shown its feasibility and efficacy in prognostic terms in patients with normal left ventricular function. Small trials have also shown it to be effective in patients with left ventricular dysfunction and wide QRS complex.•HBP for cardiac resynchronization is an alternative approach in patients with complex anatomy when conventional CRT is not possible. It provides advantages over the epicardial implant or the transventricular approach, such as the low complexity of the procedure, absence of need for indefinite oral anticoagulation, possibility of performing it in the same procedure, and a more physiological ventricular activation.•Despite the lack of randomized studies, HBP for cardiac resynchronization should be the alternative of choice to classic CRT in centers with experience with this technique. •Cardiac resynchronization therapy (CRT) in patients with complex cardiomyopathy is an added difficulty for the optimal placement of the left ventricle electrode in a coronary sinus vein. The alternative in these cases is usually epicardial implantation in most centers.•His-bundle pacing (HBP) has shown its feasibility and efficacy in prognostic terms in patients with normal left ventricular function. Small trials have also shown it to be effective in patients with left ventricular dysfunction and wide QRS complex.•HBP for cardiac resynchronization is an alternative approach in patients with complex anatomy when conventional CRT is not possible. It provides advantages over the epicardial implant or the transventricular approach, such as the low complexity of the procedure, absence of need for indefinite oral anticoagulation, possibility of performing it in the same procedure, and a more physiological ventricular activation.•Despite the lack of randomized studies, HBP for cardiac resynchronization should be the alternative of choice to classic CRT in centers with experience with this technique.