Overview
Biventricular pacing (BiVP) is a therapy for heart failure with reduced ejection fraction (HFrEF) and left bundle-branch block (LBBB) aimed at improving cardiac resynchronization 14. Conduction system pacing (CSP) is being investigated as a potentially more physiologic alternative to BiVP 14.Diagnosis
Natriuretic peptides (BNP and NT-proBNP) are globally used for heart failure diagnosis and can aid in risk stratification 2.
Heart failure with reduced ejection fraction (HFrEF) is characterized by symptomatic presentation (NYHA classes II-III) and left ventricular ejection fraction (LVEF) of 35% or less 1.
Left bundle-branch block (LBBB) is defined by a QRS duration of ≥130 milliseconds 1.
Multivariable prediction models can estimate the risk of incident heart failure in the general population 3.Management
Conduction system pacing (CSP), preferentially left bundle-branch area pacing, is being compared to biventricular pacing (BiVP) for HF-related outcomes 1.
Angiotensin receptor neprilysin inhibitors (ARNIs) are a therapeutic option in heart failure management 2.
Natriuretic peptides themselves have been used therapeutically (nesiritide, carperitide) 2.Key Recommendations
Conduction system pacing (CSP) is being investigated as a potentially physiologic alternative to conventional biventricular pacing (BiVP) for cardiac resynchronization therapy in patients with heart failure and conduction system disease 4.
CSP is being compared to BiVP in patients with symptomatic HFrEF (NYHA classes II-III), LVEF ≤35%, and LBBB (QRS duration ≥130 ms) 1.
Natriuretic peptides (BNP and NT-proBNP) are important for the diagnosis and risk stratification of heart failure 2.References
1 Zimerman A, Dal Forno A, Rohde LE, Ternes CM, Alves FD, Damiani LP et al.. Conduction System vs Biventricular Pacing in Heart Failure: The PhysioSync-HF Randomized Clinical Trial. JAMA cardiology 2026. link
2 Tsutsui H, Albert NM, Coats AJS, Anker SD, Bayes-Genis A, Butler J et al.. Natriuretic Peptides: Role in the Diagnosis and Management of Heart Failure: A Scientific Statement From the Heart Failure Association of the European Society of Cardiology, Heart Failure Society of America and Japanese Heart Failure Society. Journal of cardiac failure 2023. link
3 Nadarajah R, Younsi T, Romer E, Raveendra K, Nakao YM, Nakao K et al.. Prediction models for heart failure in the community: A systematic review and meta-analysis. European journal of heart failure 2023. link
4 Herweg B, Welter-Frost A, Wilson Ii DR, Vijayaraman P. Conduction System Pacing for Cardiac Resynchronization Therapy. Cardiac electrophysiology clinics 2022. link