Conduction System Pacing Leads: Lumenless versus Stylet-driven Technologies in Contemporary Practice

Conduction system pacing (CSP), including His bundle pacing and left bundle branch area pacing (LBBAP), has emerged as a physiological alternative to right ventricular pacing and an evolving modality for cardiac resynchronisation therapy. As clinical adoption expands, lead technology has become central to procedural success, electrical performance, and long-term safety. Historically, CSP has relied on lumenless leads (LLL), while stylet-driven leads (SDL) are increasingly used, particularly for LBBAP. Current evidence indicates that CSP procedures are feasible, reproducible, and show positive trends in outcomes for both bradycardia and heart failure patients, with both LLL and SDL achieving high implant success and comparable pacing parameters. However, differences in mechanical design may influence implantation technique, complication profiles, and long-term durability. Although observational studies and registries support the safety and effectiveness of both lead types, long-term data on lead fracture, extractability, and device-specific performance remain limited. At present, no clear superiority of one platform over the other can be established. Lead selection should therefore be individualised, guided by anatomy, operator experience and device-specific evidence, while further prospective studies are needed to optimise CSP lead design and long-term outcomes.