Abstract
Left bundle branch pacing (LBBP) has emerged as an alternative to biventricular pacing. However, a systematic stepwise approach to ensure electrical resynchronization is lacking. To define a stepwise application of LBBP criteria that will simplify implantation and guarantee electrical resynchronization. A cohort of 24 patients from the LEVEL-AT trial (NCT04054895) who received LBBP and had electrocardiographic imaging (ECGI) (CardioinsightTM Medtronic, USA) at 45 days post-implant were included. The usefulness of ECG and electrogram based criteria to predict accurate electrical resynchronization with LBBP were analyzed. A two-step approach was developed. The gold standard used to confirm resynchronization was the change in ventricular activation pattern and shortening in left ventricular activation time, assessed by ECGI. Twenty-two (91.6%) patients showed electrical resynchronization on ECGI. All patients fulfilled pre-screwing requisites: lead in septal position in left-oblique projection and W paced morphology in V1. In the first step, presence of either right bundle branch conduction delay pattern (qR or rSR in V1) or left bundle branch capture Plus (QRS ≤120ms) resulted in 95% sensitivity and 100% specificity to predict LBBP resynchronization, with an accuracy of 95.8%. In the second step, the presence of selective capture (100% specificity, only 41% sensitivity) or a spike-R<80ms (100% specificity, sensitivity 46%) ensured 100% accuracy to predict resynchronization by LBBP. Stepwise application of ECG and electrogram criteria ensured accurate assessment of electrical resynchronization with left bundle branch pacing.
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