Long-term right ventricular apical pacing has been associated with detrimental effects, including an increased risk for heart failure, atrial fibrillation, and death. Most of these adverse effects result from ventricular dyssynchrony related to perturbed ventricular depolarization. In addition, biventricular pacing has limited benefits in patients with non–left bundle branch block and severely reduced ejection fraction. Consequently, alternative pacing strategies that mimic natural physiology are desired. Recently, permanent His bundle pacing has emerged as a true physiologic form of ventricular pacing that has been shown to be safe and feasible in clinical practice.