Cardiac Electrophysiology
A more physiologic approach to pacemaker implantation — preserving the heart's natural electrical pathway for better long-term outcomes.
For decades, the standard approach to pacemaker implantation has involved placing the pacing lead at the apex of the right ventricle (RV). While effective at maintaining an adequate heart rate, right ventricular apical pacing produces an abnormal, dyssynchronous pattern of ventricular activation — the electrical signal spreads slowly through the heart muscle rather than traveling rapidly through the specialized conduction system.
Over time, this unnatural activation pattern can cause the left and right ventricles to contract out of sync, a condition known as pacing-induced cardiomyopathy. Studies have shown that a significant proportion of patients who receive high percentages of right ventricular pacing develop a measurable decline in left ventricular function, which can lead to heart failure symptoms and reduced quality of life.
Recognizing this limitation, electrophysiologists have developed a new generation of pacing techniques — collectively known as conduction system pacing (CSP) — that deliver electrical stimulation directly to the heart's native conduction system, restoring a more natural and synchronized pattern of ventricular activation.
Conduction system pacing is an advanced pacemaker implantation technique in which the pacing lead is precisely positioned within or adjacent to the heart's specialized electrical conduction system — rather than at the right ventricular apex. By capturing the conduction system directly, CSP produces a narrow, synchronized QRS complex that closely mimics the heart's natural electrical activation.
There are two primary forms of conduction system pacing currently in clinical practice:
Left bundle branch pacing is a newer and increasingly preferred form of conduction system pacing. The pacing lead is advanced through the interventricular septum and positioned to capture the left bundle branch — the main division of the conduction system supplying the left ventricle — or the left bundle branch area (LBBA) more broadly.
LBBP offers consistent capture of the conduction system, provides lower and more stable pacing thresholds, and delivers excellent sensing parameters — all of which translate to greater long-term reliability and pacemaker longevity.
Conduction system pacing offers meaningful clinical benefits compared to conventional right ventricular pacing, particularly for patients who require a high percentage of ventricular pacing.
By activating the ventricles through the native conduction system, CSP maintains synchronized contraction of the left and right ventricles, reducing the risk of pacing-induced dyssynchrony.
Clinical studies demonstrate that conduction system pacing significantly reduces the incidence of pacing-induced cardiomyopathy compared to right ventricular apical pacing.
CSP produces a narrow paced QRS complex — a marker of physiologic ventricular activation — in contrast to the wide, left bundle branch block-like QRS seen with RV apical pacing.
In patients with pre-existing left bundle branch block and reduced ejection fraction, LBBP can serve as an alternative or complement to traditional cardiac resynchronization therapy (CRT).
LBBP in particular offers stable pacing thresholds and sensing parameters over time, supporting reliable long-term device performance and battery longevity.
Patients who receive physiologic pacing report better functional status and exercise tolerance compared to those paced from the right ventricular apex.
Conduction system pacing is considered for a broad range of patients who require permanent pacemaker implantation, particularly those expected to have a high burden of ventricular pacing. Appropriate candidates may include:
Note: Not every patient requiring a pacemaker is an ideal candidate for conduction system pacing. Dr. Kim carefully evaluates each patient's anatomy, underlying conduction disease, and clinical goals to determine the most appropriate pacing strategy. The information on this page is for educational purposes and does not constitute medical advice.
If you have been told you need a pacemaker, contact our office to discuss whether conduction system pacing is right for you.
(949) 785-6300