Right bundle branch block and heart failure: Can a bifocal right ventricular pacing be an alternative to biventricular pacing?

Patients with right bundle branch block (RBBB) and heart failure (HF) are not well represented in large randomized clinical trials evaluating the efficacy of cardiac resynchronization therapy (CRT), which included mainly left bundle branch block morphology. According to a recent meta-analysis, in our series we have 14 patients with RBBB and HF treated with conventional CRT (biventricular pacing), all of them turned out to be “non-responders”.Bifocal pacing, a particular modality of simultaneous pacing with two leads implanted in the right ventricle, is a current option in case of unsuccessful biventricular pacing. In accordance with the results of the BRIGHT study, 25 patients with heart failure and unsuccessful biventricular pacing underwent right ventricular bifocal pacing implantation in our Cardiology Department, with significant improvements of NYHA functional class and left ventricular ejection fraction at 12-month follow-up (survival rate 77% after 2 years).Right ventricular bifocal pacing could be an alternative to conventional biventricular pacing in patients with RBBB and advanced HF, ensuring a more rational electric “resynchronization”, even if hemodynamic and functional benefit remains to be demonstrated.