The goals of cardiac resynchronization therapy (CRT) are to establish coordinated contraction of the heart chambers, particularly the left and right ventricles, and to improve cardiac function, symptoms, and outcomes in patients with certain heart disorders. Conduction system pacing (CSP) is an alternative method to biventricular pacing (BVP) to achieve resynchronization. CSP is achieved through stimulation of certain parts of the cardiac conduction system, the bundle of Hiss (HBP) or the left bundle branch (LBBP). Electrodes are placed at precisely determined locations, after their exact position is determined by unipolar mapping. In the case of HBP, the lead is fixed on the right side of the interventricular septum (IVS), while in LBBP the lead is fixed deeper in the IVS. It is hypothesized that CSP achieves better therapeutic results compared to BVP because it mimics the natural pathway of heart activation through conduction system stimulation. Observational studies provide support for this hypothesis. However, the lack of large randomized controlled trials (RCT) directly comparing CSP and BVP makes it difficult to draw definitive conclusions about their relative efficacy and safety. To provide the strongest level of evidence, RCTs are needed to directly compare the two therapies. Until then, tailored analysis of baseline ventricular desynchronization patterns may be useful in selecting patients who might benefit most from CSP-CRT. This approach can take into account parameters such as electrical asynchrony, QRS complex morphology and other cardiac activation characteristics to select the most suitable therapy for each patient.