Case Report: Interventricular Septal Hematoma Complicating Left Bundle Branch Pacing Lead Implantation

Abstract

Background: Left bundle branch pacing (LBBP) is a novel physiological pacing and previous studies have confirmed the feasibility and safety of it. The incidence of complications in LBBP is relatively low as reported. Here we present a case of interventricular septal hematoma complicating LBBP lead implantation.Case summary: LBBP was achieved for treatment of high-grade atrioventricular block in a 67-year-old female. Chest pain began 1 h after implantation when the electrocardiogram showed ST-T changes. Then bedside echocardiography confirmed the formation of interventricular septal hematoma. Urgent coronary angiography showed the contrast agent retention and overflow in the interventricular septum. The symptom was relieved half an hour later. Echocardiogram performed 2 h later revealed the size of the hematoma was the same as before. The electrocardiography, coronary angiography and CTA confirmed the resolution of the hematoma at 1-month follow-up. Pacing parameters and cardiac function remained stable during 6-month follow-up.Conclusion: This is the first reported case describing the clinic features and management of interventricular septum hematoma complicating LBBP. The importance of routine echocardiograms after implantation for identifying the hematoma should be highlighted.

Conduction system pacing following septal myectomy: Insights into site of conduction block

“…The depth can be assessed by the distance between hinge point and the helix of the lead, CT image, echocardiogram or contrast injection through the sheath 13,22 . Implanting the lead posteriorly is feasible as it is easier to screw deep, capture the bundle branch at lower risk of coronary artery injury 13,23,24 . To avoid lead perforation, the pacing threshold and impedance and local myocardial current of injury should be carefully monitored 15,25 .…”

“…13,22 Implanting the lead posteriorly is feasible as it is easier to screw deep, capture the bundle branch at lower risk of coronary artery injury. 13,23,24 To avoid lead perforation, the pacing threshold and impedance and local myocardial current of injury should be carefully monitored. 15,25 Adequate slack of the pacing lead is needed to reduce the risk of lead dislodgement postprocedure.…”

My preferred approach to left bundle branch pacing: Lumenless leads

“…Apart from septal perforation which require immediate recognition and repositioning, septal hematoma, 30 coronary artery injury, 31 septal coronary artery fistula, 19 and lead dislodgements are the reported complications of LBBP. Though theoretically possible, so far thromboembolic complications have not been reported both with both LLLs and SDLs after LBBP.…”

Cardiovascular imaging in conduction system pacing: What does the clinician need?

“…X-ray fluoroscopy Guide the position of the LBBP leads by contrast injection; guide HBP/LBBP leads implantation 27 Septal angiography via sheath is commonly used to estimate the depth of lead in the septum during implantation procedure 27,28,[46][47] ; with the help of angiography, distal HBP could be purposely placed on the ventricular side of the TVA 12,13 Relative subjectivity in quantifying the depth of leads and guiding the implantation of CSP lead 12,13,45 Chest Precise visualization of the venous anatomy and determination of coronary sinus and its tributaries 73 The location of CSP lead and complication assessment including lead perforation and interventricular septal hematoma 45,[74][75][76] Ionizing radiation, relatively high-dose; susceptible to beam hardening artefact from existing pacing hardware CMR Superior to CT in demonstrating mechanical dyssynchrony; better than CT at identifying septal scar, fibrosis and reversible ischemia by quantitative stress perfusion CMR provides very accurate and highresolution circumferential, radial, and longitudinal strain data using five tissue-tracking methods including myocardial tissue tagging (MR-MT) 77 with harmonic phase analysis (HARP), 78 strain-encoded imaging (SENC), 79 cine displacement encoding with stimulated echoes (DENSE), 80 velocity-encoded phase contrast MRI, 81 and manual planimetry for radial motion, 60 as well as detailed characterization of myocardial scar and viability, specifically in the basal or mid LV septum where CSP is located 33,34 Not compatible in some pacemakers and ICDs; susceptible to artefact, especially from existing MR-conditional devices (Continues)…”