Permanent left bundle branch area pacing utilizing intracardiac echocardiogram

Xiang-Fei Feng,Yi-Gang Li,Bo Liu,Peng-Pai Zhang,Qiu-Fen Lu,Yan Zhao

doi:10.1186/s12872-020-01649-0

Abstract

BackgroundRecently, left bundle branch area pacing (LBBAP) has been shown to be feasible. However, the right ventricular (RV) implantation site for LBBAP remains elusive. We believe that the RV implantation site should be located at the posteromedial basal septum, and in this paper, we propose a new method to help guide lead implantation. The aim of this study is to demonstrate the feasibility of the proposed method.MethodsThe RV implantation site was positioned by a combination of a nine-grid system on fluoroscopy and the use of intracardiac echocardiogram (ICE) and then verified by ICE.ResultsFifteen patients were enrolled for LBBAP using our method. The acute success rate was 86.7% (13/15), which demonstrated that our method is useful for assisting with lead implantation. According to ICE, the distance between the implantation site and apex (the front) and the distance between the implantation site and tricuspid annulus (the back) were 44.9 ± 10.7 and 33.2 ± 10.4 mm, respectively, and the ratio of the front and the back was 1.57 ± 0.80. The distance between the implantation site and the front junction point of the left-right ventricle (the upper) and the distance between the implantation site and the back junction point (the lower) were 33.4 ± 10.6 and 24.5 ± 10.2 mm, respectively. The ratio of the upper to the lower was 1.76 ± 1.36. These results suggest that the implantation site was at the posteromedial basal septum. The width of the QRS duration increased from 110.4 ± 33.1 ms at baseline to 114.1 ± 16.1 ms post LBBAP (P > 0.05). The operation time was 133 ± 32.9 min. The time of X-ray fluoroscopy was 21.2 ± 5.9 min. The mean time for lead positioning during LBBAP was 33.8 ± 16.6 min. During a follow-up of 3 months, the LBB capture threshold remained stable in 12 patients, except for one patient who had an increase in the LBB capture threshold to 3.0 v/0.4 ms.ConclusionsOur preliminary results indicate that the posteromedial basal septum could be seen as the implantation site for LBBAP. As a technique for LBBAP, ICE is a useful method for assisting with lead implantation. It is feasible and safe to use a nine-grid system combined with ICE for LBBAP.

Highlights

Left bundle branch area pacing (LBBAP) has been shown to be feasible
The present study demonstrated that a combination of a nine-grid system on fluoroscopy and the use of intracardiac echocardiogram (ICE) is helpful for guiding lead implantation to the desired site
The present study showed that the paced QRS duration was 114.1 ± 16.1 ms and the mean Left ventricular activation time (LVAT) was 76.2 ± 8.6 ms, and the left bundle branch (LBB) potential was found in 76.9% of patients, which suggested that left bundle branch area pacing (LBBAP) was successful

Summary

Introduction

Left bundle branch area pacing (LBBAP) has been shown to be feasible. Previous studies have demonstrated that bundle branch block could be corrected by pacing at the distal His bundle and validated the safety and clinical benefits in patients with various cardiac diseases [1,2,3,4]. Previous studies have shown that the His bundle pacing threshold significantly increased with time, even went over the capture threshold, to correct the left bundle branch (LBB) block [3, 5]. Left bundle branch area pacing (LBBAP) has been shown to be feasible by advancing the lead transvenously, deep into the IVS to pace both the LBB and adjacent ventricular tissues [8, 9]. LBB pacing may avoid later adverse impacts on the proximal His bundle or AV node caused by the progression of AV conduction delay, and LBB pacing provides more anatomical space for AV node ablation [10]

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