Conduction system pacing (CSP), which includes His bundle pacing (HBP) and left bundle branch area pacing (LBBAP), is
increasingly recognized as a physiological and clinically effective alternative to conventional right ventricular pacing
(RVP) and biventricular pacing (BiVP). The 2023 EHRA consensus provided a detailed overview of implantation
techniques and procedural endpoints, while the 2025 EHRA/ESC clinical consensus expands the discussion to clinical
decision-making and patient selection across various scenarios.
This review highlights the evolving role of CSP specifically in the context of bradycardia management and cardiac
resynchronization therapy (CRT). We focus on how recent recommendations guide the choice of pacing strategy or
resynchronization modality depending on individual clinical scenarios.

Persistent left superior vena cava (PLSVC) is not uncommonvenous return anomaly (0,3-0,5% of the general population). It is usually asymptomatic but can complicate transvenous cardiac interventions, particularly implantations of cardiac pacemakers. An 84-year-old woman was referred tohospitalwith frequent syncopal episodes, dizziness, and fatigue. ECG showed atrial fibrillation with bradycardia (35-40 bpm). The patient was fully investigated and was qualified for permanent single-chamber pacemaker implantation.The patient had an isolated persistent left superior vena cava (PLSVC). Additionally, she had right breast cancer, therefore we performed left axillary access for pacemaker implantation. The pacing lead was inserted via left axillary vein through the PLSVC to the coronary sinus. Afterwards, we looped lead in the right atrium which helped us to put it through the tricuspid valve and implant the lead in apex of right ventricle (RV). All lead measurements (sensing, threshold, impedance, slew rate)at implantation were acceptable. The patient was discharged three days post-implantation without any complications. In a 1-year follow-up we have noticed good lead parameters at interrogation and stable lead position on the X-ray. Certainly, clinicians must be aware of this anomaly and the challenges it presents during pacemaker implantation in affected patients, as well as potential solutions to address these challenges.