心脏生理性起搏旨在恢复或接近心脏自然传导与激动模式，其中以希氏束起搏和左束支起搏（LBBP）为代表的传导系统起搏（CSP）近年来发展迅速。2025年，多项随机对照研究及真实世界研究进一步丰富了CSP的循证证据。在心动过缓患者中，CSP较传统右心室起搏在维持左心室功能及降低起搏相关心肌病方面显示出潜在优势；在心力衰竭及心脏再同步治疗人群中，CSP与双心室起搏对比的研究数据不断积累，并进一步探索了LBBP优化的心脏再同步治疗等联合策略的应用价值。同时，围绕导线可靠性、除颤导线用于LBBP、无导线CSP及心房生理性起搏等方面的技术与器械创新持续推进。总体而言，CSP正逐步推动起搏治疗向更生理化与更精准化方向发展，但其长期疗效及最佳适应证仍需更多高质量研究进一步验证。

Cardiac physiologic pacing aims to restore or approximate the cardiac native conduction and activation pattern. Among these strategies, conduction system pacing (CSP), represented by His bundle pacing and left bundle branch pacing (LBBP), has developed rapidly in recent years. In 2025, several randomized controlled trials and real-world studies further strengthened the evidence base for CSP. In patients with bradycardia, CSP has shown potential advantages over right ventricular pacing in preserving left ventricular function and reducing the incidence of pacing-induced cardiomyopathy. In patients with heart failure and those indicated for cardiac resynchronization therapy, comparative data between CSP and biventricular pacing continue to accumulate, and the potential value of combined strategies such as LBBP-optimized CRT is being further explored. Meanwhile, technological and device innovations are advancing in areas such as lead reliability, the use of defibrillation leads for LBBP, leadless CSP systems, and physiological atrial pacing. Overall, CSP is progressively driving pacing therapy toward a more physiological and precision-oriented approach. However, its long-term outcomes and optimal indications still require further confirmation through high-quality studies.