We read with interest the recent article by Hayashi et al. examining the incidence of pacing-induced cardiomyopathy (PICM) in patients undergoing attempted left bundle branch area pacing (LBBAP).[1](#ref-0001) While timely given the expanding use of conduction system pacing (CSP), several methodological limitations and interpretive gaps raise concerns about the validity of the study’s conclusions, particularly regarding PICM in patients classified as having LBBAP. Whether PICM can occur with confirmed CSP remains uncertain. To date, there are no rigorously adjudicated case reports of PICM resulting from His bundle pacing or LBBP, despite the high volume of cases and strong academic interest. This question is more complex in the setting of LBBAP, where imperfect capture criteria and broad definitions – including true LBB capture, left ventricular septal capture, and deep septal pacing – create diagnostic uncertainty.