Search Results (168)

Background/Objectives: Pacemaker-induced cardiomyopathy (PICM) develops in up to 30% of patients with chronic right ventricular pacing. While biventricular (BIV) upgrade is the conventional strategy, conduction system pacing (CSP) offers a physiologic alternative recently endorsed by the 2025 ESC/EHRA Consensus Statement. However, comparative evidence in PICM is limited. Therefore, we aimed to compare outcomes of PICM patients undergoing CSP versus BIV upgrade. Methods: This retrospective analysis included consecutive PICM patients who were upgraded to CSP or BIV between 2022 and 2024 at a single, experienced center. Follow-up averaged >19 months. Clinical outcomes, lead performance, echocardiographic parameters, complications, and quality of life (QoL) were evaluated. Results: Sixty-three patients were included (CSP: 26; BIV: 37). Mean age and sex distribution were similar; both groups had wide paced QRS complexes and a high ventricular pacing burden. Baseline left ventricular ejection fraction (LVEF) was lower in BIV patients (29 ± 7% vs. 35 ± 6%, p = 0.01). Procedure duration was comparable, but fluoroscopy was shorter with CSP. QRS duration narrowed significantly in both groups (CSP: 163 ± 28→132 ± 12 ms; BIV: 171 ± 23→140 ± 18 ms; both p < 0.05). During follow-up, LVEF improved (CSP: 41 ± 8%; p = 0.008; BIV: 39 ± 8%, p = 0.0001), as did NYHA class, with no significant intergroup differences. The rates of heart failure hospitalization, all-cause mortality, and QoL were similar. Notably, 34.6% of CSP patients retained their existing generator, suggesting procedural and economic benefits. Conclusions: CSP is a feasible and potentially cost-efficient alternative to BIV upgrade in PICM, with comparable improvements in ventricular function, symptoms, and clinical outcomes. Larger prospective trials are warranted. Full article

Background/Objectives: Family-centred care is key in neonatal practice, yet parents’ and staff’s research experiences are understudied. This study aims to explore their perspectives to improve inclusiveness, communication, and effectiveness in future neonatal research design and implementation. Methods: This embedded qualitative study, conducted within the Right vEntricular function applicability in a Prediction mOdel to identify pReterm infanTs with early BronchoPulmonary Dysplasia (REPORT-BPD) feasibility study, employed a qualitative descriptive design. The sample included 10 healthcare professionals, evenly split between medical and nursing backgrounds, and 10 parents, equally distributed between mothers and fathers of preterm infants enrolled in the REPORT-BPD study. Data were collected through audio-recorded semi-structured interviews, then transcribed into Word, and imported into NVivo 14 for thematic analysis by three researchers. Results: The following four main themes were developed from 11 sub-themes that were initially extracted: (1) Trust and Assurance in the Study, reflecting the overall trust between parents and staff, emphasising its perceived study’s safety and minimal impact on the infant. (2) Emotional and Psychological Considerations, highlighting the emotional landscape of parents, including their anxieties, stressors, and support systems that help ease their concerns. (3) Communication and Engagement, underscoring the importance of effective communication and engagement between researchers and study participants. (4) Value from Participation and Constructive Feedback, capturing the dual focus on the value participants gain from their involvement in the study, and their constructive suggestions. Conclusions: This study highlights trust, communication, and emotional impact in neonatal research, emphasising ethical, family-centred design to improve engagement and recruitment in future studies. Full article

Background: Systemic sclerosis (SSc) is a rare autoimmune disease characterized by progressive fibrosis, systemic inflammation and vascular dysfunction, with manifestations that can affect multiple organs, including the heart. Cardiac involvement in SSc is often underdiagnosed, although it can have serious consequences on the prognosis, especially the occurrence of arrhythmias. These rhythm disturbances can result from direct damage to the myocardium, the conduction system, or the coronary microcirculation. Equally, the medication used can have iatrogenic consequences manifested by severe arrhythmias. Methodology: The aim of this study was to provide a synthesis of incidence, pathogenic mechanisms, diagnostic methods, and therapeutic strategies of arrhythmias associated with SSc. The potential effects of immunomodulatory therapies, such as conventional immunosuppressants and biological therapies, on cardiac electrical function were also analyzed. This narrative review could present the state of the art on arrhythmias associated with SSc, which could serve as a practical guide. In clinical practice, it is necessary to establish a team that includes cardiologists and rheumatologists as well as other specialists to contribute to a correct diagnosis followed by an optimal therapy in patients with SSc. Results: Current data suggest that diffuse myocardial fibrosis, silent ischemia, and inflammatory infiltration may alter the propagation of the electrical impulse in the heart, favoring the occurrence of arrhythmias. Atrioventricular blocks, ventricular tachyarrhythmias, and atrial fibrillation are the most commonly reported rhythm abnormalities in SSc. Also, some therapies used in the treatment of the disease may influence the arrhythmic risk. Conclusions: Cardiac arrhythmias in SSc can have a significant impact on the prognosis of patients, which is why a multidisciplinary approach is essential. Collaboration between rheumatologists, cardiologists, and electrophysiologists is crucial for the early identification and appropriate management of arrhythmic risk in this patient group. Full article

Background: Uraemic cardiomyopathy (UCM), the cardiac manifestation of chronic kidney disease, represents a significant clinical challenge that is often underdiagnosed despite being one of the strongest predictors of mortality in the chronic kidney disease (CKD) population. It develops through pathophysiological mechanisms unique to the uraemic state—left ventricular hypertrophy, myocardial fibrosis, and diastolic dysfunction—that often progress silently, sometimes even without traditional cardiovascular risk factors. Purpose: This review synthesises nephrology-centric mechanisms with clinical phenotypes and contemporary imaging (including CMR T1/T2 mapping and ECV), and proposes a CKD-stage–tailored diagnostic–therapeutic framework. It offers a distinct perspective by integrating the complex pathophysiology of UCM with practical diagnostic approaches and evolving management strategies, differentiating it from prior cardiology-focused overviews. Methods: A comprehensive literature search was conducted across Ovid MEDLINE, Embase, PubMed, Google Scholar, BMJ Best Practice, and UpToDate for studies published up to March 2025. Key findings were extracted from the final evidence set and manually verified for relevance. This review introduces a patho-mechanical cascade model of uraemic cardiomyopathy, integrating toxin-driven, metabolic, and haemodynamic axes. Nephrology-led screening protocols are proposed, leveraging proteomics and strain echo, and advocate mineralocorticoid receptor antagonists with sodium–glucose co-transporter-2 (SGLT2) inhibitor initiation at CKD Stage 3a. Cardiorenal clinics are essential for improved outcomes. Key Insights: UCM develops from a multifactorial process. This involves neurohormonal activation, oxidative stress, chronic inflammation, and exposure to toxins such as indoxyl sulfate and p-cresyl sulfate, arising from uraemia. Diagnosis is challenging, masked by overlapping features of fluid overload and anaemia. SGLT2 inhibitors, non-steroidal mineralocorticoid antagonists, and renin–angiotensin–aldosterone system modulation offer promising interventions. The effect of the dialysis modality, its timing, and renal transplantation on cardiac remodelling also emerging from recent studies. Conclusions: UCM sits at the intersection of two failing organ systems. Managing it effectively requires a paradigm shift to incorporate pharmacological and early diagnostic interventions and the integration of cardiology and nephrology care, and the timely implementation of interventions. Full article

Background: The mitral valve apparatus is a complex system that requires sufficient function of all involved structures. Previous studies have demonstrated that ventricular remodeling can cause displacement of subannular structures, including the papillary muscles, which in turn promotes the development of mitral regurgitation. Furthermore, in such cases, annuloplasty alone is often insufficient to restore optimal valve function. Instead, additional reconstruction of the subannular apparatus is associated with improved clinical outcomes. Our study aimed to analyze the topography of the papillary muscles in the mitral valve complex and their relevance for mitral valve function. Methods: In 148 patients who underwent both cardiac computed tomography (CT) and echocardiography, the position of the papillary muscles within the left ventricle was assessed. CT scans were evaluated in end-diastolic four-chamber view, two-chamber view, and short-axis view. CT analysis involved determining the position of the papillary muscles based on a modified left ventricular segmentation scheme, which subdivided the original segments into “a” and “b” subsegments in a counterclockwise manner. Furthermore, the midventricular diameter, ventricular length, as well as the angle between the papillary muscle (PM) and the left ventricular wall, were measured. Comorbidities were assessed. The presence of mitral regurgitation (MR) and ejection fraction was determined based on echocardiographic data. Echocardiography was conducted either as part of initial cardiological assessments or during follow-up examinations. For detailed statistical analysis, the patients were divided into the following groups: control group, MR-only group, coronary heart disease (CHD)-only group, and combined CHD and MR subgroup. Results: Mitral regurgitation was significantly correlated with age (p < 0.001) and hypertension (r = 0.1900, p = 0.0208), and in the MR-only subgroup, additionally with atrial fibrillation (r = 0.2426, p = 0.0462). The length (p < 0.001) and internal diameter (p < 0.001) of the left ventricle were significantly larger in men than in women. Different positions of the papillary muscles were identified. Segment 7a was significantly correlated with MR in the combined CHD and MR subgroup. In normal-sized ventricles, patients with MR and papillary muscle in 12a (p = 0.0095) or 10a (p = 0.0460) showed a significantly larger angle than patients without MR (overall dataset). Conclusions: Assessment of papillary muscle position is essential in diagnosing mitral regurgitation and should guide the consideration of subannular repair during surgical treatment. Full article

Objectives: Post-acute venous thromboembolism (VTE) is a well-recognized complication of COVID-19, driven by persistent endothelial dysfunction and thromboinflammation. Identifying simple clinical predictors of VTE may optimize therapy and limit adverse outcomes. We propose a pragmatic risk-stratification approach, based on clinical and echocardiographic parameters. Methods: We conducted a retrospective cohort study in a Romanian tertiary hospital (March 2020–April 2022) in 54 adults with laboratory-confirmed COVID-19 and imaging-confirmed VTE. Demographics, comorbidities, laboratory markers, and echocardiographic variables—particularly tricuspid annular plane systolic excursion (TAPSE), peripheral oxygen saturation (SpO₂), and left-ventricular end-diastolic diameter (LVEDD)—were collected. The primary outcome was the percentage of patients receiving systemic thrombolysis. Statistical analyses included Mann–Whitney U tests, chi-square, Spearman correlations, and multivariable logistic regression. Results: The mean age was 61.2 ± 14.7 years, and 63% were men. Eleven patients (20.4%) underwent thrombolysis. Compared with conservatively managed patients, those receiving thrombolysis had lower TAPSE (13.0 vs. 20.8 mm), lower SpO₂ (90.1 vs. 97.0%), and smaller LVEDD (24.4 vs. 46.1 mm); all differences were statistically significant. Each 1 mm decrease in TAPSE and 1% decrease in SpO₂ increased the likelihood of thrombolysis (adjusted odds ratios 1.58 and 1.34, respectively). Inflammatory markers and right-ventricular diameter were not associated with treatment. Conclusions: Reduced TAPSE, lower SpO₂, and decreased LVEDD identify post-COVID VTE patients at elevated risk of hemodynamic compromise requiring thrombolysis. A point-of-care assessment incorporating these variables may improve early risk stratification and guide therapeutic decisions. Full article

Background: Treprostinil has demonstrated effectiveness in treating Pulmonary Arterial Hypertension (PAH) and Pulmonary Hypertension associated with Interstitial Lung Disease (PH-ILD). However, tolerability remains a clinical challenge. Identifying factors influencing tolerability is important, given the adverse outcomes of PAH and PH-ILD and the potential of treprostinil to slow disease progression. Objective: This study was undertaken to identify tolerance factors and develop a predictive scoring system. Methods: A retrospective analysis of 65 patients (37 PAH, 28 PH-ILD) was conducted using patient history, pulmonary function tests (PFTs), transthoracic echocardiograms (TTEs), and right heart catheterizations (RHCs). Of these, 67.7% (n = 44) tolerated treprostinil, while 32.3% (n = 21) were intolerant. Results: Patients who tolerated treprostinil had better pulmonary function, with a higher forced expiratory volume in one second/forced vital capacity (FEV₁/FVC) ratio (82.27 ± 16.06 vs. 72.86 ± 17.76, p = 0.037) and superior right ventricular function, as indicated by higher tricuspid annular plane systolic excursion (TAPSE: 2.05 ± 0.37 vs. 1.64 ± 0.42, p < 0.001), higher cardiac index (CI: 2.51 ± 0.67 vs. 2.03 ± 0.53, p = 0.003), and improved functional status (p < 0.001). The Inhaled Treprostinil Intolerance Score (ITIS), incorporating TAPSE < 1.6, CI < 2, FEV₁/FVC < 70%, and WHO functional class (FC) 3 or 4, demonstrated strong predictive accuracy (cutoff ≥ 2, AUC = 0.884 ± 0.048, p < 0.001). Predictive performance was stronger in PAH patients (AUC = 0.921 ± 0.053) than PH-ILD (AUC = 0.833 ± 0.093, p < 0.001). Conclusions: These findings demonstrate the importance of clinical parameters in predicting treprostinil tolerance. Further investigation is warranted to refine the scoring system, particularly for PH-ILD patients. Full article

Background: Cardiac involvement is a major cause of morbidity and mortality in systemic sclerosis (SSc). Autoantibodies may help identify patients at increased cardiovascular (CV) risk. This systematic review aimed to assess the predictive value of classical and emerging SSc-related autoantibodies for cardiac involvement and their integration with imaging and cardiac biomarkers. Methods: A comprehensive literature search was conducted in PubMed, Web of Science, Scopus, and the Cochrane Library up to 16 July 2025. Studies were included if they reported associations between specific autoantibodies and cardiac outcomes (e.g., myocardial fibrosis, conduction abnormalities, arrhythmias, ventricular dysfunction) in adult patients with SSc. Data extraction and quality assessment followed PRISMA 2020 guidelines. The review protocol was registered in PROSPERO (registration ID: CRD420251107782). Results: Anti-topoisomerase I antibodies were associated with myocardial fibrosis, subclinical systolic and diastolic dysfunction, elevated cardiac biomarkers, and pathological findings on cardiac magnetic resonance imaging. Anti-centromere antibodies were linked to conduction system abnormalities, particularly among older individuals. Anti-RNA polymerase III and anti-U3 ribonucleoprotein antibodies correlated strongly with arrhythmias and pericardial involvement. Novel autoantibodies, such as anti-heart antibodies and anti-intercalated disk antibodies, were linked to early myocardial injury, although their clinical utility requires further validation. Across studies, serological markers alone were insufficient to predict cardiac outcomes without concurrent imaging or biomarker evaluation. Conclusions: Autoantibody profiling plays an important role in CV risk stratification in SSc. Combining serological testing with cardiac biomarkers and advanced imaging enhances early detection and supports individualized monitoring. Further longitudinal studies are needed to validate predictive models and optimize patient outcomes. Full article

Background/Aim of Study: Cardiovascular diseases (CVDs) are the leading cause of morbidity and mortality globally. Cardiac rehabilitation (CR) plays a pivotal role in the recovery of post-acute myocardial infarction (AMI) patients. Despite evidence supporting its clinical benefits, CR remains underutilized, especially in middle-income countries like Kazakhstan. This study aimed to evaluate the clinical effectiveness and economic impact of phase II CR among patients with AMI treated at the Almaty City Cardiology Center between 2018 and 2022. Methods: A retrospective cohort study was conducted using data from 2672 AMI patients. Two cohorts were compared: those who participated in phase II CR and those who did not. Primary outcomes included changes in left ventricular ejection fraction (LVEF), rehospitalization rates, and return to active work. Results: Economic outcomes involved direct medical costs related to initial hospitalization and follow-up care. CR participants showed significant improvements in LVEF (53.7% vs. 49.0% in non-CR patients, p < 0.001). Despite these clinical benefits, there was no significant reduction in long-term treatment costs between the CR and non-CR groups. CR users had slightly higher initial treatment costs but similar cumulative costs for subsequent treatments over two years. Importantly, government funding limitations were found to hinder the full effectiveness of CR programs in Kazakhstan. Conclusions: Phase II CR improves cardiac function in AMI patients but does not reduce long-term treatment costs. The current insufficient government funding for CR limits its broader impact. Expanding CR services and increasing funding are essential to maximize its benefits within Kazakhstan’s healthcare system. Full article

Background: Ibrutinib has been associated with an increased risk of cardiovascular adverse events (CVAEs), including atrial fibrillation (AF), hypertension (HTN), heart failure (HF), and ventricular arrhythmias (VAs). However, baseline predictors of CVAEs remain poorly characterized. In this study, we sought to identify baseline patient characteristics associated with the occurrence of ibrutinib-related CVAEs, with particular emphasis on parameters linked to the renin–angiotensin system. Methods: We conducted a prospective, single-center cohort study of consecutive patients treated with ibrutinib for B-cell malignancy, with systematic assessment of a predefined panel of potential predictors of CVAEs at baseline (NCT03678337). These predictors included demographic and clinical variables, 16 circulating biomarkers related to inflammation, fibrosis, and neurohormonal activation, as well as nine echocardiographic parameters. The primary objective was to evaluate the association between baseline patient characteristics and the occurrence of CVAEs from ibrutinib initiation through the end of follow-up. The CVAE endpoint was defined as a composite of atrial fibrillation, new or worsening hypertension, new or worsening heart failure, and ventricular arrhythmias. Statistical analyses were performed using the Wilcoxon–Mann–Whitney test or Fisher’s exact test, with a p-value < 0.05 considered statistically significant. Results: Among the 25 patients included, 7 experienced a total of 9 CVAEs over a median follow-up of 672 days. Elevated baseline plasma renin levels (>1336.10 pg/mL) were significantly associated with CVAEs occurrence (57% vs. 11%, p = 0.032). Higher baseline plasma aldosterone levels (>488.95 pg/mL) were also observed in patients who developed CVAEs, although this association did not reach statistical significance (p = 0.058). Conclusions: Baseline plasma renin level was univariably associated with CVAEs occurrence, while plasma aldosterone levels were higher among patients with CVAEs but did not reach statistical significance. These findings provide preliminary insights into the mechanisms underlying ibrutinib-related cardiovascular toxicity, suggesting a potential role for the renin–angiotensin–aldosterone system. Confirmation of this hypothesis, however, will require larger, dedicated studies. Full article

Background/Objectives: Heart failure (HF) remains a major global cause of morbidity and mortality, exerting substantial health and economic burdens. Increasing evidence suggests that systemic inflammation plays a pivotal role in HF pathophysiology, with key cytokines; interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α) contributing to disease progression and worsening cardiac function. This study aimed to evaluate serum levels of IL-1, IL-6, and TNF-α in patients with HF compared to control subjects, to assess differences in these inflammatory mediators between groups, and to explore their relationship with left ventricular ejection fraction (LVEF). Methods: A case–control study was conducted at the Madinah Cardiac Center between October 2024 and April 2025, including 61 patients diagnosed with HF and 65 age- and sex-matched controls without HF. Serum concentrations of IL-1, IL-6, and TNF-α were measured using enzyme-linked immunosorbent assay (ELISA). Clinical parameters, including LVEF and echocardiographic data, were recorded and analyzed. Results: Patients with HF demonstrated significantly elevated levels of IL-1 (6.77 ± 1.17 vs. 1.27 ± 0.42 pg/mL, p < 0.001), IL-6 (54.12 ± 4.64 vs. 9.29 ± 1.72 pg/mL, p < 0.001), and TNF-α (235.56 ± 18.88 vs. 67.37 ± 6.28 pg/mL, p < 0.001) compared to controls. Higher inflammatory marker levels were associated with reduced LVEF and more advanced New York Heart Association (NYHA) functional class, indicating a clear link between systemic inflammation and HF severity. Conclusions: The significant elevation of IL-1, IL-6, and TNF-α in HF patients highlights the pivotal role of inflammation in disease progression and severity, offering valuable insights into the underlying mechanisms that may inform future therapeutic strategies. By providing a comprehensive evaluation of these key pro-inflammatory cytokines in relation to LVEF, this study presents an integrated perspective on the inflammatory profile associated with HF. Full article

Aim: Both the arterial and venous systems independently predict mortality in septic shock, yet no bedside tools are able to integrate their assessment. Risk stratification becomes challenging when arterial parameters suggest favourable outcomes while venous parameters indicate poor prognosis, or vice versa. To address this gap, we developed the VTI-VeXUS index and conducted this proof-of-concept study to test its association with mortality. Methods: We conducted a prospective cohort study in two ICUs, enrolling adult patients with septic shock. We calculated the VTI-VeXUS index (VTI/[VeXUS+1]) from ultrasound measurements obtained within 24 h of ICU admission and stratified patients as having a high or low VTI-VeXUS index based on a cutoff of 11. We evaluated the primary outcome of mortality at 30 days using survival analysis. Results: We enrolled 62 patients. Patients with a low VTI-VeXUS index had higher rates of left ventricular dysfunction (32.3% vs. 3.2%, p = 0.006), right ventricular dysfunction (35.5% vs. 0.0%, p < 0.001), lower stroke volume (54.0 mL vs. 62.0 mL, p = 0.005), and increased 30-day mortality (adjusted HR: 3.86, 95% CI 1.23 to 12.14). Conclusions: In this exploratory proof-of-concept study, a low VTI-VeXUS index was associated with ventricular dysfunction and increased mortality. While limited by small sample size and univariate analysis, these findings suggest this novel integrated metric warrants validation in larger prospective studies. Full article

Cardiac devices have transformed the management of heart failure, ventricular arrhythmias, ischemic cardiomyopathy, and valvular heart disease. Technologies such as cardiac resynchronization therapy (CRT), conduction system pacing, left ventricular assist devices (LVADs), and implantable cardioverter-defibrillators have contributed to abated global cardiovascular risk through action onto pathophysiological processes such as mechanical unloading, electrical resynchronization, or hemodynamic optimization, respectively. While their clinical benefits are well established, their long-term molecular and structural effects on the myocardium remain under investigation. Cardiac devices dynamically interact with myocardial and vascular biology, inducing molecular and extracellular matrix adaptations that vary by pathology. CRT enhances calcium cycling and reduces fibrosis, but chronic pacing may lead to pacing-induced cardiomyopathy. LVADs and Impella relieve ventricular workload yet alter sarcomeric integrity and mitochondrial function. Transcatheter valve therapies influence ventricular remodeling, conduction, and coronary flow. Understanding these remodeling processes is crucial for optimizing patient selection, device programming, and therapeutic strategies. This narrative review integrates the current knowledge on the molecular and structural effects of cardiac devices, highlighting their impact across different disease settings. Full article

Objectives: This study sought to echocardiographic manifestations and the related risk factors affecting the prognosis of isolated congenitally corrected transposition of the great arteries (CCTGA). Methods: A total of 143 patients (≥18 years of age) were diagnosed with isolated CCTGA at Anzhen Hospital. The patients were classified as the operation group and the non-operation group depending on whether they had undergone tricuspid valve surgery. The echocardiographic data and follow-up were compared, and the primary outcomes examined were defined as death or heart transplantation. Results: The average age of 143 patients with isolated CCTGA was 39.93 ± 13.50 years. Tricuspid valve surgery was performed in 31 patients with isolated CCTGA, and 112 patients did not undergo tricuspid valve surgery. The incidence of tricuspid valve structural changes in the operation group was 39.1%, and this group had higher numbers of patients with right ventricular diastolic diameter, right ventricular systolic diameter, left atrial dimensions, and regurgitation before surgery compared with the non-operation group (p < 0.05). Follow-up results showed no significant difference in the number of death/heart transplantations, and the incidence of systemic ventricular ejection fraction (SVEF) < 40% between the two groups. The survival rate of the surgery group was higher than that of the non-surgery group, although not statistically significant (p = 0.123). Age, right ventricular end-diastolic diameter, and decreased SVEF at the first diagnosis are independent predictive risk factors for major adverse outcomes. Conclusions: Adult patients with isolated CCTGA may have structural abnormalities in their tricuspid valves. There were no significant differences in the incidence of adverse outcomes, morphological right ventricular systolic dysfunction, and survival between the surgery group and the non-surgery group. However, this study is a retrospective study, and the sample size of the surgical group is relatively small, which may limit the generalizability of the research conclusions. In the future, a prospective, large-scale study will be conducted to evaluate the therapeutic effect of tricuspid valve surgery on such patients. Full article

Right ventricular apex (RVA) pacing has historically been the default approach for cardiac pacing; however, it is associated with the development of progressive left ventricular dysfunction and heart failure (HF), particularly in patients with high pacing burdens. While advances in device programming and modern algorithms have sought to mitigate these effects, preserving physiological activation has proven to be more critical than reducing ventricular pacing. Conduction system pacing (CSP) techniques—namely, His-bundle pacing (HBP) and particularly left bundle branch area pacing (LBBAP)—have emerged as superior alternatives, enabling improved left ventricular function and reduced rates of pacing-induced cardiomyopathy (PICM). Nevertheless, despite the clinical advantages of these procedures over RVA, they face limitations including variable implantation success rates, increased pacing thresholds and lead revision rates, technical challenges, and occasional procedure prolongation. Thus, while CSP approaches represent the future of physiological pacing, RVA pacing continues to provide a necessary and reliable option in the current clinical practice. Full article