How to Choose Between His Bundle Pacing and Biventricular Pacing for Cardiac Resynchronization Therapy

  • Gaurav A. Upadhyay
  • Pugazhendhi VijayaramanEmail author
Arrhythmias (J. Bunch, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Arrythmias


Purpose of Review

The goal of this critical appraisal is to evaluate the role for His bundle pacing (HBP) in cardiac resynchronization, examine early clinical and physiologic data, as well as offer recommendations for selecting patients for HBP versus biventricular pacing for CRT.

Recent Findings

Biventricular pacing with a left ventricular (LV) coronary sinus lead has been the primary mode of delivering cardiac resynchronization therapy (CRT) for over two decades. By fusing multiple wavefronts of activation, biventricular pacing shortens and homogenizes ventricular activation, increases left ventricular ejection fraction (LVEF), reduces mitral regurgitation, and is also associated with improved clinical outcomes, including reduced heart failure (HF) hospitalization and mortality. Despite these myriad benefits, approximately one-third of patients do not derive benefit from traditional CRT. HBP is a means of delivering CRT which restores electromechanical synchrony by activating the His-Purkinje system distal to the site of proximal bundle branch block. Early clinical data suggest that CRT with HBP may be associated with comparable clinical benefits to biventricular pacing in CRT-eligible patients, although randomized data are not yet available.


The available data suggest that HBP is an alternative approach to biventricular pacing to achieve cardiac resynchronization by restoration of native Purkinje activation. The applicability is most clear in patients with typical BBB patterns. Further research and randomized studies are necessary to evaluate the role of HBP in CRT.


Cardiac resynchronization therapy His bundle pacing Biventricular pacing Left bundle branch block 



Atrial fibrillation




Bundle branch block


Complete conduction block


Cardiac resynchronization therapy


Conduction system pacing


Coronary sinus


His bundle pacing


Heart failure


His-Purkinje conduction disease


Intact Purkinje activation


Intraventricular conduction delay


Left bundle branch block


Left ventricle or left ventricular


Left ventricular ejection fraction


Myocardial infarction


New York Heart Association


Randomized controlled trial


Right bundle branch block


Right ventricular


Compliance with Ethical Standards

Conflict of Interest

Pugazhendhi Vijayaraman reports grants and personal fees from Medtronic, personal fees from Boston Scientific, personal fees from Biotronik, personal fees from Abbott, outside the submitted work. In addition, Dr. Vijayaraman has a patent pending for a His bundle pacing delivery tool.

Gaurav Upadhyay declares that he has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.From the Center for Arrhythmia Care at the University of Chicago MedicineChicagoUSA
  2. 2.Geisinger Heart InstituteGeisinger Commonwealth School of MedicineWilkes-BarreUSA

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