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Physiologic Pacing in Heart Failure
Mihail G Chelu1,2,3, Jeanne E Poole4, Kenneth A Ellenbogen5
1Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston.
The New England Journal of Medicine
|January 21, 2026
Summary
Cardiac resynchronization therapy (CRT) improves heart failure outcomes in eligible patients. Alternative pacing strategies like His bundle or left bundle branch pacing are emerging and under investigation for their efficacy compared to traditional biventricular pacing.
Area of Science:
- Cardiology
- Medical Devices
- Electrophysiology
Background:
- Cardiac physiologic pacing, or cardiac resynchronization therapy (CRT), is a treatment for heart failure patients with low ejection fraction and wide QRS complexes.
- Traditional CRT involves biventricular pacing using a right ventricular lead and a coronary sinus lead.
Purpose of the Study:
- To review the established benefits of biventricular pacing in heart failure.
- To introduce alternative cardiac physiologic pacing strategies, including His bundle and left bundle branch pacing.
- To highlight ongoing research comparing these new methods with traditional CRT.
Main Methods:
- Review of randomized trials and recent studies on cardiac pacing in heart failure.
- Analysis of clinical outcomes, exercise capacity, quality of life, and cardiac function (LVEF, ventricular volumes, mitral regurgitation).
Main Results:
- Biventricular pacing has demonstrated significant clinical benefits in over 10,000 heart failure patients.
- Benefits are most pronounced in patients with left bundle-branch block and QRS duration ≥150 msec.
- Conduction system pacing (His bundle or left bundle branch) is emerging as a viable alternative.
Conclusions:
- Biventricular pacing remains a cornerstone therapy for selected heart failure patients.
- Conduction system pacing offers a promising alternative, with ongoing trials to establish its comparative effectiveness and safety.
- Further research is crucial to define the optimal pacing strategy for individual patients.
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