Intravascular imaging (IVI) has emerged as a pivotal tool in percutaneous coronary intervention (PCI), offering superior visualization of coronary anatomy compared with conventional angiography. This literature review synthesizes the latest evidence from randomized trials and meta-analyses published since 2022, assessing the comparative efficacy of IVI modalities—including intravascular ultrasound (IVUS) and optical coherence tomography (OCT)—in complex coronary lesions. Multiple landmark trials, such as RENOVATE-COMPLEX PCI, ILUMIEN IV, OCTOBER, and OCTIVUS, demonstrated that IVI-guided PCI significantly improves procedural outcomes, stent optimization, and clinical endpoints such as target-vessel failure, myocardial infarction, and stent thrombosis. OCT was shown to be particularly beneficial in bifurcation and left main interventions, while IVUS consistently improved outcomes in long lesions and complex anatomies. Despite some trials not meeting their primary clinical endpoints, substudy findings and pooled analyses support a shift toward routine IVI use in anatomically complex cases. Consequently, updated guidelines now recommend IVI as a Class I indication in select patient populations. These findings underscore the need for broader clinical adoption and training in IVI techniques to enhance PCI outcomes.

Heart failure remains a major cause of morbidity and mortality despite advances in guideline-directed medical therapy and device-based treatment. Cardiac resynchronization therapy delivered by conventional biventricular pacing constitutes an established therapeutic strategy for selected patients with heart failure with reduced ejection fraction and electrical desynchrony. Left bundle branch area pacing has emerged as a physiological pacing strategy that directly engages the conduction system, providing more effective electrical and mechanical resynchronization. Current evidence from observational studies, randomized pilot trials, and recent multicentre data suggest that left bundle branch pacing may achieve greater QRS narrowing, more favourable pacing thresholds, improved left ventricular ejection fraction, and reduced heart failure hospitalizations compared with conventional biventricular pacing in selected patients. This review summarizes the rationale, implantation criteria, patient selection, and current clinical evidence supporting left bundle branch pacing as an alternative pacing modality in heart failure patients. Despite encouraging available data, larger randomized trials with longer follow-up and broader patient populations are required to clarify long-term safety and to determine whether left bundle branch pacing should be adopted as a routine alternative to conventional cardiac resynchronization therapy. From a personalized medicine perspective, the choice between conduction system pacing and conventional biventricular pacing should be guided by individual patient characteristics, including conduction phenotype, QRS morphology and duration, myocardial scar burden, heart failure aetiology, coronary venous anatomy, and the chance of achieving confirmed conduction-system capture. This review therefore renders left bundle branch pacing within an individualized, phenotype-guided resynchronization strategy rather than as a universal replacement for biventricular pacing.