Clinical indications for conduction system pacing in routine practice: 2025 survey from the HMEA project

Background Conduction system pacing (CSP) has emerged as a physiological alternative to right ventricular pacing and, in selected patients, to biventricular pacing for cardiac resynchronization therapy (CRT). The 2025 ESC consensus statement outlined potential indications for CSP, real-world adoption remains unclear. Purpose To assess contemporary CSP use in a European country, focusing on clinical indications. Methods An online survey of 23 questions was distributed to 101 centers of the Italian Home Monitoring Expert Alliance (HMEA) network. The questionnaire captured CSP use across predefined clinical scenarios based on international recommendations. Results Ninety-two centers (91% response rate) completed the survey. Almost all (98%) performed at least one CSP procedure in the past year, with left bundle branch area pacing (LBBAP) accounting for 95% of cases (Figure). CSP was most frequently adopted in atrioventricular block with anticipated high ventricular pacing burden, where 28–49% of centers used it as first-line therapy depending on ejection fraction. In atrioventricular node ablation, CSP was the preferred approach in 40% of centers with preserved/mid-range LVEF and 27% with reduced LVEF. Use in sinus node dysfunction was limited (first-line in 5%). In heart failure, CSP was mainly used as a bailout for failed or non-response to CRT, though 27% of centers adopted it first-line in non-LBBB patients. CSP-optimized CRT procedures were rarely reported. Conclusion CSP, predominantly LBBAP, has entered routine clinical practice in Italy, particularly for AV block and as a rescue strategy in CRT. Adoption remains heterogeneous, underscoring the need for randomized trials to define class I indications.