Introduction His bundle pacing (HBP) and left bundle branch area pacing (LBBAP) have emerged as attractive alternatives to traditional biventricular pacing to achieve cardiac resynchronization therapy. Early reported results have been inconsistent, particularly amongst patients in whom initial placement with traditional approaches has been unsuccessful or those with complex anatomy or congenital abnormalities. In this report, we describe the use of three‐dimensional electroanatomic mapping (EAM) in five selected cases. Methods Five patients from multiple clinical sites underwent EAM‐guided HBP or LBBAP by highly trained electrophysiologists with significant experience with conduction system pacing. Each patient in this series underwent EAM‐guided conduction system pacing due to complex anatomy and/or prior failed lead implantation. Results EAM‐guided lead implantation was successful in all five cases. Capture thresholds were relatively low and patients continued to have evidence of successful lead implantation with minimum 1‐month follow‐up. The fluoroscopy time varied, likely owing to the variable complexity of the cases. Conclusions The use of EAM, in combination with traditional intracardiac electrograms with or without fluoroscopy, allows more targeted and precise placement of leads for HBP and LBBAP pacing. Further investigation is needed to determine this strategy's long‐term performance and to optimize patient selection.

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A man in his 60s was admitted to the intensive care unit with necrotizing pancreatitis and biliary stenosis complicated by pneumonia, hypoxic respiratory failure, and convulsive seizures. The cardiology service was consulted to evaluate recurrent episodes of wide complex tachycardia observed on telemetry (Figure , A). The patient did not lose consciousness during these episodes.Question: What is the cause of this wide complex tachycardia? InterpretationThe electrocardiogram (ECG) strip (Figure , A) starts with 2 sinus beats conducted with normal PR interval, QRS duration and morphology, and QT interval. Then wide complex tachycardia initiates and terminates. The wide complex tachycardia peaks twist around the isoelectric baseline, consistent with torsades de pointes. 1 Of note, the QT interval in this patient is not prolonged, which is usually a prerequisite for torsades de pointes.