Background: Traditional right ventricular pacing is effective for bradyarrhythmia treatment but may cause electrical dyssynchrony, pacing-induced cardiomyopathy, atrial fibrillation, and heart failure progression. His bundle pacing is a physiological pacing strategy designed to preserve native ventricular activation.

Objective: To compare clinical outcomes, safety, procedural performance, and limitations of His bundle pacing versus traditional right ventricular pacing.

Methods: This narrative review summarizes contemporary evidence from observational studies, registries, meta-analyses, and randomized clinical experience comparing His bundle pacing with traditional pacing.

Results: His bundle pacing is associated with narrower QRS duration, better preservation of left ventricular function, lower risk of pacing-induced cardiomyopathy, and possible reduction in heart failure hospitalization compared with traditional right ventricular pacing. However, it may require longer implantation time, higher capture thresholds, increased lead revision risk, and greater operator expertise.

Conclusion: His bundle pacing offers a more physiological alternative to traditional pacing, especially in patients expected to require a high ventricular pacing burden. Traditional pacing remains simpler, widely available, and reliable, but physiological pacing strategies are increasingly favored in selected patients.