Introduction
In recent years, His bundle pacing has emerged as a more physiologic alternative to right ventricular (RV) pacing1. However, despite a reasonable success rate2, this procedure has yet to gain universal acceptance. Direct left bundle branch or intra-septal pacing has been recently proposed as a valid, technically feasible alternative3 that may result in comparable benefits. Initial reports with this method have been encouraging, although long-term data remain scarce. We present a case of an adverse outcome possibly caused by direct left bundle branch pacing and reversed by an upgrade to a biventricular system.