Primer of conduction system pacing for the general cardiologist

Conduction system pacing (CSP), which encompasses His bundle pacing and left bundle branch area pacing, has resulted in a paradigm shift in the management of patients with bradycardia pacing indications and heart failure (HF) patients with reduced ejection fraction (HFrEF) requiring cardiac resynchronisation therapy (CRT).While right ventricular pacing is simple and reliable, chronic dyssynchronous activation can lead to pacing-induced cardiomyopathy, HFrEF, incident atrial fibrillation and an associated increase in mortality. Traditional CRT with biventricular (BiV) pacing improves morbidity and mortality in patients with HFrEF and dyssynchrony, yet its efficacy is limited by non-response rates and non-physiological (epicardial to endocardial) BiV activation. CSP seeks to recruit the intrinsic His-Purkinje network to restore physiologic BiV activation and hopefully achieve a more consistent and physiological resynchronisation.This review provides a practical primer for the general cardiologist on the rationale, techniques and clinical evidence supporting CSP. We summarise key trials, highlight real-world outcomes and offer guidance on patient selection, follow-up and future directions. Clinical pearls and tables are provided to distil practical insights.