Pacing-induced cardiomyopathy (PICM) is a well described phenomenon that occurs in a minority of patients exposed to high-burden right ventricular (RV) pacing. Although several risk factors may identify patients at increased risk of PICM, many individuals tolerate high-burden RV pacing for many years without obviously deleterious effects, and the ability to identify those at highest risk remains insufficient. Treatment of PICM has primarily involved upgrade to cardiac resynchronization therapy once signs of cardiomyopathy manifest. The emergence of His bundle pacing may offer an opportunity to prevent PICM before it occurs.