BACKGROUND: Conduction system pacing, which includes His bundle pacing and left bundle branch area pacing (LBBAP), is becoming increasingly common in clinical practice. His bundle pacing, introduced over two decades ago, continues to see growing use, while LBBAP is gaining traction due to its broader target area and shorter procedure times. However, complications such as septal perforation and lead-related issues may still arise. This case report explores the evaluation and management of recurrent syncope in the context of bifascicular block (BFB), highlighting the importance of thorough assessment, continuous ECG monitoring, and the potential need for permanent pacemaker implantation. CASE SUMMARY: A 60-year-old woman with a history of myocardial infarction, Type II diabetes, and dyslipidaemia presented with recurrent syncope and BFB, for which a LBBAP device was implanted in August 2023. In February 2024, she was admitted again due to recurrent syncope and frequent premature ventricular contractions. Cardiac magnetic resonance imaging revealed two localized myocardial scars: one at the basal anterior wall from the 2018 ischaemic event and another in the mid infero-septal wall at the site of the LBBAP lead. During her hospital stay, she experienced multiple episodes of near fainting due to orthostatic hypotension, indicative of underlying autonomic neuropathy. DISCUSSION: This narrative explores the evolving landscape of cardiac pacing techniques, with a focus on LBBAP, highlighting its advantages over traditional methods while also acknowledging potential complications. Additionally, it emphasizes the importance of a comprehensive workup for syncope and the need for tailored interventions that extend beyond pacemaker implantation.