PO-02-109 FACILITATING LEFT BUNDLE BRANCH PACING BY IDENTIFYING THE TIP OF THE TRIANGLE OF KOCH WITH RIGHT ATRIAL SEPTOGRAM

Abstract

Left bundle branch (LBB) pacing has emerged as an alternative to His bundle (HB) pacing for physiological stimulation of the ventricles. Current techniques to achieve LBB pacing can be challenging and time consuming, as they require the placement of a catheter/lead to reference the HB We sought to develop a method to facilitate the achievement of LBB pacing. Permanent LBB pacing was performed in 104 consecutive patients with symptomatic bradycardia. A right atrial septogram (RAS) was performed in all the patients to locate the His bundle region (HBR). Briefly, 8-10 cc of contrast were injected trough the Medtronic C315 His delivery sheath while fluoroscopy and cine runs were obtained in the RAO 20-degree projection. These images provided the visualization of an approximately 90-degree angle composed by the medial aspect of the tricuspid valve annulus (TV) anteriorly and the superior aspect of the interatrial septum (IAS) superiorly. The apex of this angle coincides with the tip of the triangle of Koch, where the HBR resides (Figure 1A). This area was referenced by placing a sticky paper arrow on the monitor screen (green arrow). The C315 sheath was then advanced approximately 2 cm anteriorly and 1 cm inferiorly from the level of the HBR to the right ventricular septum (RVS) in the location of the LBB area (LBBA) (Figure 1B). Subsequently, a 3830 Medtronic SelectSecure bipolar lead was advanced through the C315 sheath into the interventricular septum by turning the lead clockwise multiple times in the selected LBBA. The advancement of the lead was monitored by fluoroscopy visualization of the interventricular septum plane with intermittent injections of small amounts of contrast media in the LAO 30-degree projection (Figure 1C), by tracking the impedance measurements and analyzing morphology changes of the unipolar paced QRS morphology. LBB capture was confirmed by current ECG criteria. LBB pacing was successfully achieved in 96 % of the patients (100 out of 104 patients). Twenty nine female. Mean age 75 +/10 years. The mean procedure time for LBB lead insertion was 17.5 +/- 15 minutes. For LBB lead performance see table within figure 1. No acute complications were observed. This study demonstrates that the RAS guided technique provides a highly successful and safe approach to achieve LBB pacing by readily identifying the HBR.