Cardiac pacing may induce haemodynamic alterations. RV pacing may have deleterious effects including a decrease of LV function as well as an increase of heart failure hospitalizations and mortality. Biventricular pacing is established in patients with heart failure and left bundle branch block or chronic AV block to improve haemodynamics. In the future, device optimization employing quadripolar leads or multisite pacing may further increase the rate of responders. However, cinical evaluation represents the most important tool to recognize the necessity for device optimization. Device algorithms are not yet successfully established to replace clinical and echocardiographic evaluation.