Cardiac resynchronization therapy constitutes a cornerstone in advanced heart failure treatment, when there is evidence of dyssynchrony,
especially by electrocardiography. However, it is plagued both by persistently high (~30%) rates of nonresponse and by deterioration of right
ventricular function, owing to iatrogenic dyssynchrony in the context of persistent apical pacing to ensure delivery of biventricular pacing. Left
ventricular pacing has long been considered an alternative to standard biventricular pacing and can be achieved as easily as inserting a single
pacing electrode in the coronary sinus. Although monoventricular left ventricular pacing has been proven to yield comparable results with the
standard biventricular modality, it is the advent of preferential left ventricular pacing, combining both the powerful resynchronization potential of
multipolar coronary sinus and right-sided electrodes acting in concert and the ability to preserve intrinsic, physiological right ventricular activation. In this review, we aim to present the underlying principles and modes for delivering left ventricular pacing, as well as to highlight advantages of preferential over monoventricular configuration. Finally, current clinical evidence, following implementation of automated algorithms, regarding performance of left ventricular as compared with biventricular pacing will be discussed. It is expected that the field of preferential left ventricular pacing will grow significantly over the following years, and its combination with other advanced pacing modalities may promote clinical status and prognosis of patients with advanced dyssynchronous heart failure.