I read with great interest the elegant article by Ali et al.1 on His bundle pacing in issue 17.2 of AER. I do concur with the authors’ view and conclusions. However, there are two issues that may merit further attention.
First, specific His-bundle pacing is indeed the reasonable option that mimics the natural ventricular excitation. However, no benefit of mid-septal over apical pacing has been shown in randomised comparisons.2,3 Is this because of the relatively short-term follow-up that did not allow apical pacing to expose its deleterious effects on the ventricle or just reflects the fact that mid-septal is not equivalent to specific His pacing?
Second, acute results of His-bundle pacing are comparable to these of cardiac resynchronisation therapy (CRT).4,5 Do the authors believe that we have enough data to implement this principle in clinical practice, even before a randomised trial confirms this notion? That should have a tremendous impact on cost and efficacy of pacing in the setting of intractable heart failure, especially in view of the cost and complications of CRT, as demonstrated in the BLOCK-HF trial.6