The Role of Conduction System Pacing in Heart Failure: Current Evidence and Future Directions

Conduction system pacing (CSP), including His bundle pacing and left bundle branch area pacing, offers a promising approach to treating heart failure (HF) with conduction system disease. This review examines the evidence supporting CSP as an alternative to traditional biventricular pacing in improving outcomes for HF patients. Studies were reviewed focusing on CSP's clinical efficacy in patients with left bundle branch block (LBBB) and those who are nonresponders to cardiac resynchronization therapy. Findings suggest that CSP enhances electrical and mechanical synchronization, improving left ventricular ejection fraction, reducing QRS duration, and leading to better clinical outcomes, including decreased HF-related hospitalizations and reduced all-cause mortality. Despite these benefits, technical challenges such as lead placement and device-related complications remain. The review concludes that CSP may offer significant advantages over conventional cardiac resynchronization therapy, particularly in patients with persistent conduction delays or myocardial scar. However, larger randomized controlled trials are needed to validate the long-term efficacy and safety of CSP across diverse patient populations. Future advancements in pacing technologies and personalized treatment strategies are expected to further refine CSP's role in HF management.