T-wave inversions during conduction system pacing: A marker of more physiological ventricular activation

Abstract

Permanent myocardial pacing can preserve adequate heart rates and improve symptoms and mortality in patients with bradycardia. Conventional right ventricular (RV) pacing is far from the optimal treatment since up to 20% of patients experience a reduction in the left ventricular (LV) ejection fraction, which can lead to heart failure (HF). This was the main incentive for developing 'conduction system pacing (CSP)' techniques that target (directly or indirectly) the capture of conduction tissue, initiating more physiological ventricular activation. Although His bundle pacing (HBP) leads to the best ventricular synchrony, proper positioning is complicated, requires high pacing thresholds, and is associated with lower sensing values. For these reasons, left bundle branch area pacing (LBBAP), where the lead tip is deployed in the left subendocardial septal area, is currently preferred over HBP.