AIMS: The field of conduction system pacing (CSP) is evolving, and our aim was to obtain a contemporary picture of European CSP practice. METHODS AND RESULTS: A survey was devised by a European CSP Expert Group and sent electronically to cardiologists utilizing CSP. A total of 284 physicians were invited to contribute of which 171 physicians (60.2%; 85% electrophysiologists) responded. Most (77%) had experience with both His-bundle pacing (HBP) and left bundle branch area pacing (LBBAP). Pacing indications ranked highest for CSP were atrioventricular block (irrespective of left ventricular ejection fraction) and when coronary sinus lead implantation failed. For patients with left bundle branch block (LBBB) and heart failure (HF), conventional biventricular pacing remained first-line treatment. For most indications, operators preferred LBBAP over HBP as a first-line approach. When HBP was attempted as an initial approach, reasons reported for transitioning to utilizing LBBAP were: (i) high threshold (reported as >2 V at 1 ms), (ii) failure to reverse bundle branch block, or (iii) > 30 min attempting to implant at His-bundle sites. Backup right ventricular lead use for HBP was low (median 20%) and predominated in pace-and-ablate scenarios. Twelve-lead electrocardiogram assessment was deemed highly important during follow-up. This, coupled with limitations from current capture management algorithms, limits remote monitoring for CSP patients. CONCLUSIONS: This survey provides a snapshot of CSP implementation in Europe. Currently, CSP is predominantly used for bradycardia indications. For HF patients with LBBB, most operators reserve CSP for biventricular implant failures. Left bundle branch area pacing ostensibly has practical advantages over HBP and is therefore preferred by many operators. Practical limitations remain, and large randomized clinical trial data are currently lacking.

1st Department of Cardiology Interventional Electrocardiology and Hypertension Jagiellonian University Medical College Kraków Poland

Arrhythmia Unit Department of Cardiology Virgen de la Arrixaca University Hospital Murcia Spain

Cardiology Department Beacon Hospital Dublin Ireland

Department of Cardiology 'F Miulli' Hospital Acquaviva delle Fonti Bari Italy

Department of Cardiology 3rd Faculty of Medicine Charles University and University Hospital Kralovske Vinohrady Prague Czech Republic

Department of Cardiology Cardiovascular Research Institute Maastricht Maastricht University Medical Center Maastricht The Netherlands

Department of Cardiology Centre Hospitalier Universitaire de Rouen Charles Nicolle Rouen France

Department of Cardiology Centro de Investigaciones Biomédicas en RED en Enfermedades Cardiovasculares Madrid Spain

Department of Cardiology Heart Center Dresden University Hospital Technische Universität Dresden Dresden Germany

Department of Cardiology Northwest Clinics Alkmaar The Netherlands

Department of Cardiology Shaare Zedek Medical Center and Hebrew University faculty of medicine Jerusalem Israel

Department of Cardiology University Hospital Antwerp Edegem Belgium

Department of Cardiology University Hospital of Geneva Geneva Switzerland

Department of Internal Medicine 2 with Cardiology Angiology and Intensive Care Ordensklinikum Linz Elisabethinen Linz Austria

Division of Cardiology and Angiology 2 University Heart Center Freiburg Bad Krozingen Bad Krozingen Germany

Electrocardiology Department Medical University of Lodz Lodz Poland

National Heart and Lung Institute Imperial College London Du Cane Road London W12 UK

Semmelweis University Cardiovascular Center Budapest Hungary

Unidad de Arritmias Servicio de Cardiología Hospital Universitario y Politécnico La Fe Valencia Spain

Wiltshire Cardiac Centre Great Western Hospitals NHS Foundation Trust Swindon UK

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