His-Purkinje conduction system pacing and atrioventricular node ablation

His-Purkinje conduction system pacing (HPCSP) in the form of His bundle pacing and left bundle branch pacing allows normal ventricular activation, thereby preventing the adverse consequences of right ventricular pacing. One potential area where HPCSP could be used is in the field of atrioventricular (AV) node ablation in patients with atrial fibrillation refractory to medical therapy and/or catheter ablation. His bundle pacing has been established for several years, with centres from North America, Europe and China publishing their experience. The differing patterns of His bundle capture are clearly described with established guidance as to how to implant such systems. Left bundle branch pacing has only recently been reported, but there are several advantages with better pacing parameters and lower risk of threshold change after AV node ablation. Six studies have been identified in the literature which describe the experience of His bundle pacing in patients requiring AV node ablation. Overall the results are positive and favour this new technique; however, they are limited by low numbers of patients and non-randomised study design. An observational study was recently published demonstrating better outcomes with left bundle branch pacing in a small number of patients with left ventricular dysfunction and atrial fibrillation that underwent AV node ablation. HPCSP has the potential to be the primary pacing modality in patients with atrial fibrillation requiring AV node ablation. However, it is essential that this is confirmed in large randomised clinical trials.