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Patients with symptomatic heart failure (HF) and left bundle branch block (LBBB) are currently treated with biventricular pacing (BiV) which has a Class IA recommendation. Given the possibility to re-establish the inter and intra-ventricular synchrony, BiV is commonly referred to as cardiac resynchronization therapy (CRT). This wording is widely utilized and over time the terms BiV and CRT have become interchangeable. Conduction system pacing (CSP) is emerging as a valid therapeutic opportunity to obtain CRT restoring the native conduction via the Purkinje network. Therefore the acronym CRT is no longer synonymous with BiV only but could also refer to CSP. A terminology update is needed to include the resource of CSP to ensure better communication among all the stakeholders involved in managing recipients of cardiac devices and should be a fundamental step in advancing the quality of patient care. Making use of the NBG code to describe the implantable cardiac device would ease such terminology update, since only the first three positions of the five letters NBG code are commonly utilized, while the last two are rarely used.

Objective To compare the prevalence and progression of tricuspid regurgitation (TR) after the implantation of right-ventricular pacing cardiac implantable electronic devices (CIEDs) versus biventricular pacing devices. Background TR in patients with CIEDs is often linked to mechanical interference from leads, but studies show TR can also progress with leadless pacemakers, suggesting a direct effect of pacing. Methods We conducted a retrospective analysis of 549 patients who received a pacemaker (PM), implantable cardioverter defibrillator (ICD), or cardiac resynchronization therapy (CRT) device. Follow-ups were conducted after one year and at least three years with aggregate interrogation and transthoracic echocardiography performed. Patients were categorized into two groups: right-ventricular (RV all ) pacing and biventricular (BiV) pacing. Results Median age was 68 [57–76] years, with 419 (76.3%) being male. Of these patients, 21.5% received an ICD, 30.4% a PM, and 48.1% a CRT device (RV all : n  = 285; BiV: n  = 264). BiV patients had worse left ventricular (LV) function and more pronounced evidence of RV dilatation at baseline. After three years, a relevant TR was more prevalent in the RV paced patients (RV all : 17.4%; BiV: 9.8%). Also, an increase in TR grade of ≥I° and ≥II° was more frequent in the RV all group. While tricuspid annular systolic excursion (TAPSE) deteriorated in the RV all group, it was preserved in the BiV group. Conclusions RV pacing was associated with a higher prevalence and severity of TR after CIED implantation compared to BiV pacing, but this effect might also be explained by significant differences in the group’s clinical characteristics.

Background Right ventricular (RV) pacing is the standard treatment for atrioventricular (AV) block but may impair left ventricular (LV) function over time. Biventricular (BiV) pacing offers a physiologic alternative, though prior evidence has been mixed, particularly after the BioPace trial. Methods PubMed, ScienceDirect, Google Scholar, and the Cochrane Library were searched through May 2025 for randomized controlled trials (RCTs) comparing BiV and RV pacing in AV block. Thirteen RCTs ( n  = 3,685) met the inclusion criteria. Outcomes included heart failure (HF) hospitalization, all-cause mortality, six-minute walk distance (6MWD), cardiovascular (CV) death, and LVEF (%) at follow-up. Results BiV pacing significantly reduced HF hospitalizations (risk ratio [RR] = 0.83, 95% CI 0.69–0.98; p  = 0.03) and better preserved LVEF (mean difference = 6.17%, 95% CI 3.85–8.49; p  < 0.00001). No significant differences were observed in all-cause mortality (RR = 0.87, 95% CI 0.70–1.08; p  = 0.21) or CV death (RR = 0.95, 95% CI 0.75–1.21; p  = 0.70). RV pacing showed a borderline improvement in 6MWD (mean difference = 10.3 m, 95% CI − 0.1 to 20.7; p  = 0.05). Conclusion In patients with AV block and high pacing burden, BiV pacing reduced HF hospitalizations and better preserved systolic function compared with RV pacing. These findings support a burden-based pacing strategy, while CRT use should be individualized, considering patient profile and procedural factors. Systematic review registration This systematic review and meta-analysis was retrospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO) under ID 1080380. Clinical trial number Not applicable.

Background/Objectives: Pacemaker-induced cardiomyopathy (PICM) develops in up to 30% of patients with chronic right ventricular pacing. While biventricular (BIV) upgrade is the conventional strategy, conduction system pacing (CSP) offers a physiologic alternative recently endorsed by the 2025 ESC/EHRA Consensus Statement. However, comparative evidence in PICM is limited. Therefore, we aimed to compare outcomes of PICM patients undergoing CSP versus BIV upgrade. Methods: This retrospective analysis included consecutive PICM patients who were upgraded to CSP or BIV between 2022 and 2024 at a single, experienced center. Follow-up averaged >19 months. Clinical outcomes, lead performance, echocardiographic parameters, complications, and quality of life (QoL) were evaluated. Results: Sixty-three patients were included (CSP: 26; BIV: 37). Mean age and sex distribution were similar; both groups had wide paced QRS complexes and a high ventricular pacing burden. Baseline left ventricular ejection fraction (LVEF) was lower in BIV patients (29 ± 7% vs. 35 ± 6%, p = 0.01). Procedure duration was comparable, but fluoroscopy was shorter with CSP. QRS duration narrowed significantly in both groups (CSP: 163 ± 28→132 ± 12 ms; BIV: 171 ± 23→140 ± 18 ms; both p < 0.05). During follow-up, LVEF improved (CSP: 41 ± 8%; p = 0.008; BIV: 39 ± 8%, p = 0.0001), as did NYHA class, with no significant intergroup differences. The rates of heart failure hospitalization, all-cause mortality, and QoL were similar. Notably, 34.6% of CSP patients retained their existing generator, suggesting procedural and economic benefits. Conclusions: CSP is a feasible and potentially cost-efficient alternative to BIV upgrade in PICM, with comparable improvements in ventricular function, symptoms, and clinical outcomes. Larger prospective trials are warranted.

Background Usage of active fixation bipolar left ventricular (LV) leads represents an alternative approach to the more commonly used passive fixation quadripolar leads in cardiac resynchronization therapy (CRT). We compared a bipolar LV lead with a side screw for active fixation and passive fixation quadripolar LV leads. Methods Sixty‐two patients were before CRT implantations randomly allocated to receive a bipolar (n = 31) or quadripolar (n = 31) LV leads. Speckle‐tracking radial strain echocardiography was used to define the LV segment with latest mechanical activation as the target LV segment. The electrophysiological measurements and the capability to obtain a proximal position in a coronary vein placed over the target segment were assessed. Results Upon implantation, the quadripolar lead demonstrated a lower pacing capture threshold than the bipolar lead, but at follow‐up, there was no difference. There were no differences in the LV lead implant times or radiation doses. The success rate in reaching the target location was not significantly different between the two LV leads. Conclusions The pacing capture thresholds were low, with no significant difference between active fixation bipolar leads and quadripolar leads. Active fixation leads did not promote a more proximal location of the stimulating electrode or a higher grade of concordance to the target segment than passive fixation leads. An active fixation bipolar left ventricular pacemaker lead was compared to passive fixation quadripolar leads in a randomized trial. There were no differences between the types of leads in pacing capture thresholds, procedure times, or success rate to reach the target location.

Impact of variability in the measured parameter is rarely considered in designing clinical protocols for optimization of atrioventricular (AV) or interventricular (VV) delay of cardiac resynchronization therapy (CRT). In this article, we approach this question quantitatively using mathematical simulation in which the true optimum is known and examine practical implications using some real measurements. We calculated the performance of any optimization process that selects the pacing setting which maximizes an underlying signal, such as flow or pressure, in the presence of overlying random variability (noise). If signal and noise are of equal size, for a 5-choice optimization (60, 100, 140, 180, 220 ms), replicate AV delay optima are rarely identical but rather scattered with a standard deviation of 45 ms. This scatter was overwhelmingly determined (ρ = −0.975, P  < 0.001) by Information Content, , an expression of signal-to-noise ratio. Averaging multiple replicates improves information content. In real clinical data, at resting, heart rate information content is often only 0.2–0.3; elevated pacing rates can raise information content above 0.5. Low information content (e.g. <0.5) causes gross overestimation of optimization-induced increment in VTI, high false-positive appearance of change in optimum between visits and very wide confidence intervals of individual patient optimum. AV and VV optimization by selecting the setting showing maximum cardiac function can only be accurate if information content is high. Simple steps to reduce noise such as averaging multiple replicates, or to increase signal such as increasing heart rate, can improve information content, and therefore viability, of any optimization process.

PurposeDual-chamber (DDD) pacing has been used for treatment of patients with hypertrophic obstructive cardiomyopathy (HOCM). Due to inconclusive results in prior trials, current guidelines assign DDD pacing a class IIb indication in selected patients. Prior observations indicate that lack of clinical improvement may result from suboptimal effect of DDD pacing with non-physiological AV intervals due to fusion of intrinsic and paced QRS complex.MethodsThe Triple Chamber Pacing in Hypertrophic Obstructive Cardiomyopathy Patients (TRICHAMPION) trial is a prospective, randomized, single-blinded, multicenter study to investigate the benefit of atrial synchronous biventricular pacing (CRT-P) in highly symptomatic HOCM patients with severe left ventricular outflow tract (LVOT) obstruction who are not candidates for ablative therapies. AV node ablation is used as key tool to optimize AV intervals in patients with QRS fusion. The primary endpoint is the percentage of patients with symptomatic improvement at 12 months, defined as improvement of New York Heart Association functional class, in the Minnesota Living with Heart Failure Questionnaire score and increased cardiopulmonary exercise endurance.ConclusionsThe aim of the TRICHAMPION trial is to investigate the benefit of optimized atrial synchronous biventricular pacing in absence of QRS fusion in highly symptomatic HOCM patients with severe LVOT obstruction who are not candidates for ablative therapies.

Pacemaker implantation remains the only therapeutic option that improves morbidity and mortality for patients with symptomatic bradycardia. However, pacing from the right ventricular apex can induce dyssynchronous activation of the ventricles, increase sympathetic activation, cause abnormalities in myocardial perfusion, worsen cardiac output and endothelial function and may be associated with adverse cardiovascular outcomes. This article reviews the current knowledge on the pathophysiology of pacing-induced cardiovascular disease and current strategies to avoid and mitigate the adverse effects of right ventricular pacing.

Cardiac resynchronization therapy by biventricular pacemaker/ICD implantation is a validated therapy for patients affected by heart failure with asynchrony of ventricular contraction. Considering the large number of parameters which play a role in cardiac resynchronization therapy, a comprehensive numerical model of cardiocirculatory system could be a useful tool to support clinical decisions. A variable elastance model of ventricles was updated to model the interventricular septum and to simulate the interventricular and the intraventricular desynchrony, and the effect of the biventricular stimulation. In addition, a numerical model of the biventricular pacemaker, which drives the beginning of the heart chambers and interventricular septum contraction, was also developed. In order to validate the model, five patients affected by dilated cardiomyopathy were analysed by echocardiography and electrocardiography before implantation, 24 h and 3 months after the implantation. The developed numerical model permits to reproduce clinical data and to estimate the trend of parameters that are difficult to measure (i.e. left ventricular systolic elastance). Furthermore, the model permits to study the effect of different biventricular pacemaker temporizations on hemodynamic variables.

Cardiac resynchronization therapy (CRT) improves measures of systolic function and clinical status. However, its effect on diastolic function is not well established. Commonly used parameters of diastolic function are measured from echocardiography, using pulse wave and tissue Doppler technologies, as well as timing and deformation data. Review of the existing studies that address the relationship between diastolic function and CRT shows conflicting data, but general trends can be deduced. Baseline elevated filling pressure appears to identify patients most likely to derive improvement in that particular parameter. Intrinsic relaxation does not appear to be significantly impacted by CRT. Generally, changes in diastolic properties after CRT appear to be linked to changes in systolic function. Specific therapy aimed at diastolic asynchrony is lacking, partly due to an unclear relationship between diastolic asynchrony and diastolic dysfunction, and the inability to specifically impact diastolic timing with a systolic intervention such as CRT.