His bundle pacing: Initial experience and lessons learned

•A century of physiologic and clinical investigations have demonstrated the benefits of preserving the normal rapid multisite coordinated activation of the ventricles as determined by the His-Purkinje activating system.•Permanent direct His bundle pacing is well defined by electrophysiologic criteria.•Since the initial experience, permanent His bundle pacing has become recognized as an optimal pacing mode in patients both with preserved and diseased His-Purkinje activating systems.

Direct His bundle pacing provides the most physiologic means of artificial pacing of the ventricles with a preserved His-Purkinje system and may play a role in patients with a diseased intrinsic conduction system. We describe our initial motivations and experience with permanent direct His bundle pacing and important lessons learned since that time.