This case report presents the successful implantation of a left bundle area pacing lead in a 64-year-old male with a history of bundle branch ventricular tachycardia and consequent therapeutic ablation of the right bundle branch. Despite extensive conduction disease, effective physiological pacing was achieved as part of a cardiac synchronisation pacing

Conduction system pacing has brought abut a shift in the delivery of device therapy. Although gaining growing adoption, challenges remain; one of which is higher fluoroscopy times. Yang et al describe reducing and even aiming to eliminate fluoroscopy in left bundle area pacing implantation and replacing lead visualisation with transthoracic echocardiography. This editorial reviews these methods in context with recent developments in conduction system pacing and current literature.