Conduction system pacing in the Netherlands: current practice and perspectives from a nationwide survey

Background

Conduction system pacing (CSP) is an emerging physiological pacing strategy that has gained increasing adoption worldwide and was recently endorsed in the EHRA 2025 consensus statement. However, contemporary national data describing the use and clinical indications of CSP are lacking. This study aimed to evaluate the current CSP practices in the Netherlands among high-volume CSP implanting centers.

Methods

An online questionnaire consisting of 18 questions was distributed among implanting cardiologists in high-volume CSP implanting centers in October 2025. The survey included center characteristics, pacing indications, technical aspects of CSP implantation, follow-up strategies and perceptions and barriers to widespread adoption.

Results

The survey was completed by all fifteen centers, representing >90% of high-volume CSP implanting hospitals nationwide.

• Profile of respondents: Among high-volume centers, 47% (7/15) centers performed 40–100 implantations annually, while 53% (8/15) exceeded 100 cases per year. All centers predominantly perform left bundle branch area pacing (LBBAP). His bundle pacing (HBP) is nowadays rarely used (13%).

• Pacing indications: CSP was most commonly used for bradycardia indications with left ventricular ejection fraction (LVEF) >40%, cardiac resynchronization therapy (CRT) in case of failed coronary sinus lead implantation and for pace-and-ablate procedures (all 100%). The majority of centers also used CSP for bradycardia with LVEF <40% (60%) or in CRT non-responders (53%). A minority of centers reported using CSP as primary CRT (27%).

•Technical aspects: For HBP, lumenless leads are preferred (75%). For LBBAP, the preference was more balanced with a favor for lumenless over stylet driven leads (44%). In case of HBP, 42% of centers never use a backup lead, whereas for LBBAP this is 67%. The three most commonly used criteria for confirmation of CSP capture were the R-wave peak time in V6 / stimulus left ventricle-activation time in V5 (100%), right bundle branch block configuration in V1 (87%), and the interpeak time V6–V1 (73%). Implanters use 12-channel ECG (93%) and an electrophysiology system for this purpose (86%).

• Follow-up: Follow-up was primarily conducted using ECG to evaluate CSP capture.

• Perceptions and future directions: The three main barriers to broader implementation of CSP are limited guideline indications, unknown lead performance, and prolonged procedure duration. Nevertheless, 94% centers expect to perform more LBBAP procedures in the future.

Conclusion

This nationwide survey provides a comprehensive snapshot of CSP practice in the Netherlands. As anticipated by the 2023 EHRA physician survey, LBBAP has now replaced HBP as the dominant CSP approach. Most centers have incorporated CSP into routine clinical practice for bradycardia indications and although technical and training barriers remain, there is a strong consensus that CSP represents the future of pacing.Figure 1.Figure 2.