Bachmann's bundle pacing: toward physiologic atrial activation

Bachmann's bundle (BB) pacing is an emerging physiological atrial pacing strategy designed to preserve interatrial conduction and coordinated atrial activation. Conventional right atrial appendage pacing may produce non-physiological activation, contributing to atrial dyssynchrony, impaired left atrial function, and increased risk of atrial fibrillation. Because BB is the predominant pathway for right-to-left atrial conduction, targeted BB pacing can shorten the P-wave duration and improve atrial synchrony. Recent fluoroscopic, electrogram-guided, and P-wave morphology criteria have improved confirmation of BB capture. Available studies suggest that BB pacing is feasible and generally safe, with potential benefits in reducing the burden of atrial arrhythmias. However, the long-term clinical outcomes remain uncertain. Larger prospective studies are needed to standardize BB capture criteria, define optimal patient selection, and assess long-term outcomes.