[Comment on the European Society of Cardiology (ESC) Clinical Consensus Statement on the indication for conduction system pacing].

The Clinical Consensus Statement of the European Society of Cardiology (ESC) updates expert opinions on conduction system pacing (CSP). It does not represent a focused update of the ESC pacemaker guidelines of 2021 since that would require the publication of new results of randomized trials. But an official statement became necessary because at the time of preparing the ESC guidelines on pacing and cardiac resynchronization, only very limited data on left bundle branch pacing were available rendering this form of pacing almost completely ignored in the recommendations. Second, daily implantation practice has changed substantially worldwide since the advent of CSP. Third, basically all international heart rhythm societies apart from the ESC have published new guidelines on the use CSP in 2023 which differ significantly from the European recommendations. The Clinical Consensus Statement on CSP of the ESC differs from the 2021 ESC guidelines only in nuances since ESC statutes do not allow that an ESC expert opinion paper substantially contradict current ESC guidelines. However, it is important for daily practice that CSP be recommended as a potential alternative to right ventricular pacing in patients with good left ventricular function or rare ventricular pacing is expected. Similarly, CSP is recommended as an alternative to biventricular pacing (BiVP) in reduced left ventricular function, in context with ablation of the atrioventricular node, in heart failure with wide QRS complex and for upgrading in pacing-induced cardiomyopathy. Finally, CSP is recommended in nonresponders to BiVP.