Conduction System Pacing

Conduction System Pacing (CSP)

Conduction system pacing (CSP) is a cardiac pacing strategy that directly stimulates the heart’s native electrical conduction pathways, aiming to produce a more physiologic ventricular activation than traditional right ventricular (RV) pacing

What it means

Instead of pacing the RV apex or septum, CSP targets:

His bundle pacing (HBP)
Left bundle branch area pacing (LBBAP)

Types of conduction system pacing

Bundle Pacing (HBP)

Lead is placed at the His bundle
Produces the most physiologic activation possible
Can correct some bundle branch blocks

Limitations

Higher pacing thresholds
Lead fixation can be challenging
Thresholds may rise over time

Left Bundle Branch Area Pacing (LBBAP)

Lead is screwed deep into the interventricular septum to capture the left bundle or nearby fibers
Increasingly favored in practice

Advantages

Lower and more stable thresholds than HBP
High success rates
Can resynchronize ventricles effectively, even in LBBB

Why CSP is important

Common indications

CSP vs traditional CRT

Current status:

Feature	CSP	Biventricular CRT
Physiologic activation	Very high	Moderate
Lead complexity	Single ventricular lead	Multiple leads
Coronary sinus dependence	No	Yes
Evidence base	Growing	Extensive