My preferred approach to left bundle branch area pacing: Stylet-driven leads

Adoption of left bundle branch area pacing using stylet-driven lead in a tertiary academic training center: Learning curve and acute procedural outcomes

Background

Left bundle branch area pacing (LBBAP) has recently emerged as a strategy for conduction system pacing.

Objective

The purpose of this study was to evaluate the initial learning experience and acute procedural success in adopting this procedure in an academic training center.

Methods

A retrospective review of LBBAP procedures using the Biotronik Solia stylet-driven lead from June 2022 to December 2023 was performed. Procedural and fluoroscopy times with electrocardiographic and pacing parameters were evaluated to determine safety and acute procedural outcomes.

Results

A total of 69 patients (mean age 75 ± 12 years; 60.9% male) underwent LBBAP implantation over 18 months for standard pacing indications by 10 implanters (including 7 fellows-in-training) without previous experience in LBBAP technique. Mean total procedural time was 74.1 ± 23.5 minutes, and mean fluoroscopy time for LBBAP lead insertion was 9.3 ± 5.4 minutes. Mean paced QRS duration was 115.2 ± 15.5 ms, and mean left ventricular activation time was 79.4 ± 14.5 ms. An rsR' pattern was achieved in 76.8%. LBBAP was successful in 78.3% (overall 43.5% single deployment; median 2 [interquartile range 1-3]) with excellent LBBAP lead parameters: threshold 0.8 ± 0.4 V at 0.4 ms; sensing 9.4 ± 4.2 mV; impedance 627 ± 131 Ω. Acute procedural complications included damaged lead helix requiring a second lead (4.3%), pneumothorax (2.9%), and acute LBBAP lead dislodgment (1.4%). Septal perforation occurred in 10.1% of cases with no acute sequelae. When analyzed in tertiles, the number of lead deployment attempts was significantly reduced with no changes to procedural success rates with increasing experience.

Conclusion

Adoption of LBBAP with stylet-driven lead in an academic training center is feasible and safe, with satisfactory success rates and no overly steep learning curve.

Comparison of Procedural Outcomes of Lumenless Fixed-Helix Versus Stylet-Driven Extendable-Helix Lead Systems in Left Bundle Branch Pacing: COMPARE LBBP

BACKGROUND

Left bundle branch pacing (LBBP) has emerged as a safe and effective alternative to right ventricular pacing. Traditionally, LBBP is performed with lumenless lead (LLL); however, the use of stylet-driven lead (SDL) is on rise. We aimed to assess acute success and procedural outcomes of SDL versus LLL for LBBP.

METHODS

One hundred consecutive patients with bradyarrhythmia, indication of cardiac resynchronization therapy, or ablate and pace strategy were randomized in a 1:1 fashion to the SDL and LLL arms. Tendril STS lead with a CPS Locator 3D catheter and SelectSecure 3830 lead with a C315HIS catheter were used in the SDL and LLL arms, respectively. LBBP was confirmed by standard criteria with measurements done on Labsystem Pro.

RESULTS

Patients in the LLL arm were significantly younger (71.9±11 versus 76.4±8.9 years; P=0.02); all other baseline characteristics were not significantly different. Acute success in LBBP was similar with SDL versus LLL (90% versus 92%; P=0.7). In patients with successful LBBP, screw attempts were not significantly different between the groups (2.3±1.7 in SDL versus 1.9±1.3 in LLL; P=0.2). Implant duration (11±9.6 versus 9.9±7.1 minutes; P=0.4), mean fluoroscopy dose (65.3±82.7 versus 53.5±50.5 mGy; P=0.5), and fluoroscopy time (7.8±4.8 versus 7.4±4 minutes; P=0.7) were also not different in the SDL versus the LLL arm, respectively. Incidence of lead failure (P=0.6), microdislodgement (P=1), and macrodislodgement (P=0.6) were not significantly different. Pacing threshold was comparable at implant and on follow-up at 1, 3, and 6 months.

CONCLUSIONS

LBBP was feasible with both lead systems with similar success rate and low capture threshold. No significant difference was observed in procedure duration or fluoroscopy use. No major complications were recorded with either lead.

REGISTRATION

URL: https://www.anzctr.org.au; Unique identifier: ACTRN12624000304538.

Case Report: Extraction of a stylet-driven lead for left bundle branch area pacing >2 years after implantation

Left bundle branch pacing has recently emerged as a significant alternative to right ventricular pacing. The rate of implanted stylet-driven septal leads is expected to increase substantially in the coming years, along with the need to manage long-term complications. Experience in extracting these leads is currently very limited; however, the number of complex extractions is anticipated to increase in the future. We report a complex case involving the extraction of a long-dwelling Solia lead used for left bundle branch pacing in a 21-year-old man. The lead was extracted through the implant vein 27 months after implantation, using a methodology that involved a locking stylet and compression coil. The new lead insertion was challenging due to venous occlusion but after successful venoplasty, the His lead was successfully implanted. The postoperative course was uneventful, demonstrating the feasibility of extraction without complications.

Extraction of stylet-driven pacing lead for left bundle branch area pacing

We present a case where a stylet-driven pacing lead was successfully extracted from the left bundle branch area pacing, 10 months after implantation. The procedure was performed without any complications, using a standard stylet and employing gentle counterclockwise rotations of the lead body.

Feasibility and safety of left bundle branch area pacing in patients with septal hypertrophy

INTRODUCTION

Left bundle branch area pacing (LBBAP) aims to provide physiological ventricular activation during pacing. Left ventricular septal hypertrophy (LVSH) might be challenging for LBBAP due to the thickness of the interventricular septum and potential presence of septal scar. This study assesses the feasibility, safety, and outcome of LBBAP in patients with LVSH using primarily stylet-driven leads (SDL).

METHODS

Adult patients with LVSH who underwent LBBAP between March 2019 and November 2022 were enrolled. Baseline patient characteristics, procedural data and postprocedural results were collected. The feasibility of LBBAP in LVSH patients was compared to a cohort of LBBAP patients with normal septal wall thickness (NST).

RESULTS

Seventeen LVSH and 133 NST patients underwent LBBAP with successful implantation achieved in 15 LVSH patients (88%). Mean implant depth was 17.2 ± 1.9 mm, with 53% proven left bundle branch (LBB) capture. Paced QRS duration (146 ± 14 ms) and V6 R-wave peak time (V6 RWPT; 79 ± 20 ms) were comparable between patients with and without septal hypertrophy, although patients with NST had higher rates of proven LBB capture (71% vs. 53%). In LVSH pacing thresholds (0.6 ± 0.3 V at 0.4 ms) and R-wave amplitude (13.9 ± 5.6 mV) were favorable and remained stable at follow-up. At 12 months, 87% of patients had stable or improved left ventricular ejection fraction.

CONCLUSION

The results of the study indicate that LBBAP in patients with LVSH is safe and feasible and no lead-related complications were observed despite a mean implant depth exceeding 15 mm. LBBAP using SDL results in favorable pacing and electrocardiographic characteristics in LVSH patients, comparable to patients with NST.