Elsevier

Heart Rhythm

Volume 18, Issue 8, August 2021, Pages 1318-1325
Heart Rhythm

Clinical
Devices
Contrast-enhanced image-guided lead deployment for left bundle branch pacing

https://doi.org/10.1016/j.hrthm.2021.04.015Get rights and content

Background

Left bundle branch pacing (LBBP) is a novel conduction system pacing modality, but pacing lead deployment remains challenging.

Objectives

This study aimed to evaluate the feasibility of visualization-enhanced lead deployment for LBBP implantation and to assess LBBP characteristics on the basis of lead tip location.

Methods

Successful LBBP with a well-defined lead tip location by visualization of the tricuspid value annulus in 20 patients was retrospectively analyzed to develop an image-guided technique to identify the LBBP target site. This technique was then prospectively tested in 60 patients who were randomized into 2 groups, one using the standard approach (the standard group) and the other using the image-guided technique (the visualization group). The procedural details, electrophysiological characteristics, and short-term follow-up were compared between groups.

Results

LBBP was successfully achieved in 28 patients in the standard group and in 29 in the visualization group. The procedural and fluoroscopic durations in the visualization group (66.76 ± 14.62 and 7.83 ± 2.05 minutes) were significantly shorter than those in the standard group (85.46 ± 20.19 and 11.11 ± 3.51 minutes) (P < .01). The number of lead deployment attempts in the visualization group was lower than that in the standard group (2.03 ± 1.18 vs 2.96 ± 1.17; P < .01), and the proportion of left bundle branch potential recorded was higher (79.3% vs 46.4%; P = .01).

Conclusion

Using a visualization technique, the procedural and fluoroscopic durations for LBBP implantation were significantly shortened with fewer lead repositioning attempts.

Introduction

His bundle pacing (HBP) is the most physiological pacing modality with promising clinical outcomes. However, procedural difficulties and frequent long-term instability of pacing capture threshold limit its wide adoption.1 Left bundle branch pacing (LBBP) is an alternative conduction system pacing technique. LBBP results in a relatively narrow paced QRS duration, fast left ventricular activation time, and low and stable pacing capture thresholds.2 However, the implantation procedure of LBBP remains empirical. Compared with HBP implantation that locates the target site by recording the His bundle (HB) potential, LBBP cannot identify a left bundle branch (LBB) potential from the right ventricular septum before the pacing lead helix is advanced to the left side of the interventricular septum. Recently, our group reported a novel tricuspid valve annulus (TVA) visualization technique for HBP implantation, which may help to locate the HB region and shorten the procedural and fluoroscopic durations.3,4 In the present investigation, we explore the feasibility of a similar technique for LBBP implantation. Herein, we report the procedural and fluoroscopic durations in LBBP implantation by using the visualization technique in comparison with the current standard approach. Additionally, we assessed the relationship between lead tip locations and the electrical characteristics of LBBP both acutely and in follow-up.

Section snippets

Study design and patient population

The present study consisted of 2 phases. The exploratory phase was to establish the visualization technique for LBBP implantation by retrospectively analyzing lead locations in 20 patients with successful LBBP implantation. Phase 2 was a prospective randomized study of 60 consecutive patients with symptomatic bradycardia referred for pacemaker implantation. All patients underwent LBBP implantation with either the standard approach (the standard group) or the standard implantation with

Baseline characteristics

In the prospective phase, 60 consecutive patients were randomized with 30 patients in each group. The baseline data of the 2 groups are summarized in Table 1. In brief, there were no significant differences in baseline characteristics between groups. More patients had atrioventricular block than sinus node dysfunction as an indication for pacing. Twenty percent of patients in the standard group and 16.7% in the visualization group had bundle branch block. Overall, cardiac structure and function

Discussion

In this prospective randomized study, we evaluated the feasibility of LBBP implantation guided by the technique of visualizing anatomical markers for the lead tip entry site. Compared with the standard group, the visualization technique (1) facilitates LBBP implantation with significantly reduced procedural and fluoroscopic durations, (2) reduces the number of deployment attempts, and (3) increases the proportion of LBB potential recorded.

Conclusion

A novel visualization technique for LBBP lead deployment shortens procedural and fluoroscopic durations for LBBP implantation. This approach requires fewer lead repositioning and results in a higher proportion of LBB potential recorded for confirming successful LBBP. These findings will help facilitate LBBP implantation.

Acknowledgements

We thank Yixiao Xing, MD (Peking University Hospital of Stomatology) for providing help in graphic design.

References (13)

There are more references available in the full text version of this article.

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    The first case of permanent left bundle branch pacing(LBBP)was reported in 2017, which was achieved using the 3830 lead (SelectSecure; Medtronic Inc., Minneapolis, MN) delivered through a fixed curve sheath (C315HIS; Medtronic) via a transvenous approach to capture the left conduction system.1 Since then, LBBP has rapidly evolved into clinical practice because it is a simpler and more reliable procedure with a high success rate, and satisfactory pacing/sensing parameters compared with His bundle pacing (HBP).2–4 In recent years, several researchers have described various implant techniques and new methods to facilitate LBBP-.5

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Funding sources: This work was supported by the National Natural Science Foundation of China (grant number 82070349), Fundamental Research Funds for Central Universities (grant number 3332019047), and Innovation Funds for Graduate Students of Peking Union Medical College (grant number 2019-1002-33).

Disclosures: Dr Zhou is an employee of Medtronic. Dr Gold receives consulting fees from Medtronic and Boston Scientific. The rest of the authors report no conflicts of interest.

Registration number: ChiCTR2100041794.

1

The first 3 authors contributed equally to this study.

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