[Conduction system pacing (CSP) for every patient? : Should CSP replace classical right ventricular and biventricular stimulation?]

Direct stimulation of the conduction system (conduction system pacing, CSP) can be performed at multiple levels and for different indications. The most physiological option is direct stimulation of the bundle of His, which is technically simpler and possible at the level of the left bundle branch and with more stable electrical parameters. This stimulation results not only in "nice" ECG leads but, above all, in a homogeneous, synchronous, physiological contraction pattern, especially of the left ventricle. In many situations there is a direct competition with the established stimulation modalities of the right ventricle in isolated bradycardia and cardiac resynchronization therapy (CRT) in heart failure. A clear distinction and recommendation in the guidelines are not yet definitive, also due to pending and constantly accumulating data and an evolving portfolio of sheaths and leads from all manufacturers; however, overall there is a clear preference for CSP over right ventricular apical pacing, if possible but this still needs to be confirmed in comparison to CRT.