The ‘10 Commandments’ from the 2025 ESC/EHRA Clinical Consensus Statement on Indications for Conduction System Pacing (CSP)

Conduction system pacing (CSP) is a relatively new area of pacing that is being increasingly adopted as a more physiological substitute to traditional form or right ventricular pacing, as well as emerging as an alternative to biventricular cardiac resynchronisation therapy (BiV-CRT).1 When the 2021 European Society of Cardiology (ESC) guidelines on pacing2 were being formulated, CSP had already been investigated for several years, mainly in the form of His bundle pacing (HBP) in cases of atrioventricular (AV) block, for pacing in the setting of AV nodal ablation and as an alternative to BiV-CRT in selected patients. Due to limited evidence at that time, a conservative approach towards HBP was taken, with no recommendations regarding left bundle branch area pacing (LBBAP). Since then, new evidence from observational studies, randomized studies (albeit small), and meta-analyses has emerged as to the safety and efficacy of CSP. The European Heart Rhythm Association (EHRA) has recently published a consensus document on CSP implantation to standardize the technique.3 Recent European surveys4,5 and the recent MELOS registry6 are examples of the extensive use of CSP. The 2024 updated EHRA core curriculum now includes CSP in its syllabus.7 Given the increasing published evidence on the benefits of CSP, which have led to its increasing adoption, and to reconcile the European recommendations on pacing and cardiac resynchronization with current practice, we decided to update advice on indications for CSP. The consensus document8 represents a collaborative effort of the ESC and EHRA, as well as EHRA’s sister societies: the Asian-Pacific Heart Rhythm Society (APHRS), the Canadian Heart Rhythm Society (CHRS), the Heart Rhythm Society (HRS), and the Latin American Heart Rhythm Society (LAHRS). It follows the principles of the ESC and EHRA scientific document committees in terms of evaluating evidence and providing advice, with anonymous voting for adoption of advice. The authors include early CSP adopters (all of whom also have extensive experience with BiV-CRT), experts who primarily perform BiVP, non-implanting heart failure specialists, and a patient representative. We thus aim to provide a balanced and consensual view from multiple perspectives. Furthermore, this document is the first to adopt the new icons for depicting advice (see Table 1) which will also be applied to consensus documents from the ESC and its Associations, in the interest of clarity and harmonization. Depiction of the new icons for providing advice for ESC and Associations Consensus Documents (top). ‘10 Commandments’ listing the main messages from the CSP indications consensus documents (bottom) Depiction of the new icons for providing advice for ESC and Associations Consensus Documents (top). ‘10 Commandments’ listing the main messages from the CSP indications consensus documents (bottom) The main messages regarding CSP indications are listed as ‘10 Commandments’ in the table. The consensus document also compares indications for CSP with those of right ventricular and biventricular pacing, and provides insight into future perspectives. We realize that our document is ephemeral as the field is evolving rapidly. However, while awaiting more data from ongoing randomized controlled trials which will consolidate CSP indications in future ESC Guidelines, the document provides readers with updated advice on how to best provide care for their patients. Y.M. is a consultant for Edwards Lifesciences Corp. (Irvine, California). M.G. has participated in Medtronic advisory boards, for which he has received minor compensation.