Two Trials Comparing Conduction System Pacing and Biventricular Pacing

Cardiac resynchronization therapy (CRT) with biventricular pacing (BiVP) remains a cornerstone treatment for patients with heart failure with reduced ejection fraction and left bundle-branch block (LBBB), supported by decades of randomized evidence demonstrating reductions in mortality and heart failure hospitalization. In parallel, conduction system pacing (CSP), most commonly delivered as left bundle-branch area pacing (LBBAP), has emerged as a physiologically appealing alternative, aiming to directly recruit the His-Purkinje system. Because early observational studies and small randomized trials reported superior electrical resynchronization and larger improvements in left ventricular ejection fraction (LVEF) with CSP than with BiVP, CSP is becoming increasingly popular for CRT in patients who have a strong indication for BiVP. Cardiac resynchronization therapy (CRT) with biventricular pacing (BiVP) remains a cornerstone treatment for patients with heart failure with reduced ejection fraction and left bundle-branch block (LBBB), supported by decades of randomized evidence demonstrating reductions in mortality and heart failure hospitalization. In parallel, conduction system pacing (CSP), most commonly delivered as left bundle-branch area pacing (LBBAP), has emerged as a physiologically appealing alternative, aiming to directly recruit the His-Purkinje system. Because early observational studies and small randomized trials reported superior electrical resynchronization and larger improvements in left ventricular ejection fraction (LVEF) with CSP than with BiVP, CSP is becoming increasingly popular for CRT in patients who have a strong indication for BiVP.