Left bundle branch area pacing - restoring the natural order

Abstract

Introduction: Recent studies have shown that His-bundle pacing could be an alternative in patients requiring cardiac resynchronization therapy as it is comparable or better in terms of amelioration of ventricular activation, narrowing of the QRS complex, or clinical outcomes. However, in case of high threshold at the level of His-bundle or inability to correct conduction through a diseased His-Purkinje system other option should be searched like left bundle pacing. Patient concerns: A 77-year-old man presented to the Emergency Department for dizziness and dizziness and lightheadedness due to an intermittent 2:1 atrioventricular block with a QRS complex morphology of a major left branch block. Diagnosis: Given the documented symptomatic 2:1 AV block, according to the European Guideliness the patient was considered to have a class 1 indication of permanent double chamber cardiostimulation. Interventions: A lead delivery system with a C315 His catheter and a Select Secure 3830 69 cm pacing lead were placed at the His bundle area with important narrowing of the QRS complex but with an unacceptable high threshold. The delivery system was moved towards the apex 1,5 cm and the lead screwed deep into the septum until capture of the left bundle branch was achieved with complete normalization of the conduction troubles. Outcomes: At 3 month follow-up the patient was asymptomatic and the pacing and sensing thresholds remained at same values as during implantation: 0.75/0.4 ms and 14 mV respectively. Conclusion: Left bundle-pacing represents the next step of His-Purkinje system pacing to overcome all difficulties related to His-bundle pacing.

Case report: What course to follow when left bundle branch pacing encounters acute myocardial infarction?

“…Many articles and systematic reviews have demonstrated the effectiveness of LBBP ( 3 ), which was confirmed in our patient. However, some researchers have cautioned that additional studies are needed to validate the safety of LBBP ( 6 ) as some complications have been reported including septal perforation and thromboembolism ( 7 ), septal arterial injury ( 8 ), and lead dislodgement ( 9 ).…”

“…To overcome the limitations of right ventricular apical pacing (RVAP) such as electrical and mechanical dysynchrony and a high risk of heart failure ( 1 ), two physiologic stimulation techniques have been employed—namely, HBP and LBBP ( 2 ). Although HBP has some demonstrated benefits ( 3 ) such as specific activation of the conduction system and has been broadly adopted, it has certain drawbacks including the difficulty of identifying the precise location of the His bundle, unstable pacing threshold, or lead dislodgement rate of 5–10%, large atrial signals, or low R-wave amplitude that complicate pacing management, and heart block distal to the pacing cite ( 4 ). The LBBP is a novel technique for stimulating the cardiac conduction system.…”

Overview of Current Strategies Aiming at Improving Response to Cardiac Resynchronization Therapy

“…However, in addition to all these promising studies, difficulties in the implantation technique and problems in atrial oversensing and ventricular capture threshold stability, which may cause problems in the clinical follow-up of patients, hinder the widespread use of HBP. 30 - 32 Unfortunately, Electrogram (EGM) recordings in patients with HBP are insufficient in detecting transitions between the NS-HBP, S-HBP, BBB recruitment, and RV septal capture when making threshold adjustments during device controls. Therefore, His-capture threshold tests should be performed under 12-channel ECG guidance.…”