Bridging the gap: optimizing conduction system pacing for cost-effectiveness and widespread adoption in low-resource settings

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Abstract
Background: Right ventricular apical (RVA) pacing often leads to interventricular dyssynchrony and pacing-induced cardiomyopathy. Conduction system pacing (CSP), particularly Left Bundle Branch Area Pacing, provides a physiologic alternative. In Limited Resource Countries (LRCs) like Thailand, Cardiac Resynchronization Therapy (CRT) under-penetration persists due to high costs and a shortage of operators skilled in coronary venous anatomy. Objective: To share the experience and provide clinical update of CSP as a sustainable, cost-effective physiological pacing strategy to improve access to advanced arrhythmia management in resource-constrained environments. Methods: This review explores the implementation of minimalist protocols and CSP-based CRT. Scalability strategies include specialized training programs, device reprocessing, and the establishment of regional longitudinal registries to bridge infrastructure gaps. Results: CSP-based CRT can reduce device costs by nearly 50% compared with traditional triple-lead systems. This modality effectively mitigates the hemodynamic risks of RVA pacing while bypassing the technical and financial barriers of conventional CRT. Discussion: Despite its advantages, CSP adoption requires overcoming infrastructure challenges, specifically the lack of automated remote monitoring. Optimizing clinical outcomes in LRCs necessitates standardized training, robust data collection, and innovative resource management to ensure equitable access to life-saving technology.

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