BackgroundLeft bundle branch area pacing(LBBAP) results in right bundle branch(RBB) delay pattern due to pre-excitation of the left-bundle. The mechanism of right-ventricular(RV) activation during LBBAP is largely unknown ObjectivesThe aim of the study is to analyze the electrophysiological characteristics pf RV activation by mapping the RBB during LBBAP and its clinical correlation. MethodsConsecutive patients who underwent successful LBBAP were included. RBBB, RV-paced rhythm or suboptimal intracardiac electrograms were excluded. LBBAP was performed with continuous recording of His-bundle(HB) and RBB-electrograms. RV activation was classified into 3 types based on the intracardiac electrogram –(a) type-I(RBB mediated) (b) type-II(transeptal activation) and (c) type-III(fusion pattern). ResultsOverall 86 patients(94% LBBP;6%LVSP) were included. Mean age 59.6±12.8 years. Non-selective to selective capture transition was noted in 85%(n=73). In patients with baseline normal QRS(n=47), during selective-LBBP(S-LBBP;n=39) the most common pattern was type-I(n=35;87%) while during non-selective LBBP(NS-LBBP;n=44) type-III patten(n=40;91%) was common. In patients with LBBB(n=39), type-III pattern was common during both S-LBBP and NS-LBBP. Type-I pattern was noted only in patients with retrograde HB-activation during S-LBBP. LVSP showed type-II activation in both groups. Patients without retrograde HB activation had higher LV end-diastolic diameter, lower LVEF and prolonged HV-interval as compared to those with retrograde HB activation. ConclusionPhysiological RBB mediated (type-I) activation of the RV was the most common pattern observed during S-LBBP in patients with intact retrograde HB activation. Type-III pattern was the most common pattern observed during NS-LBBP with fusion of multiple wavefronts from anterograde RBB activation, septal myocardial, and transverse inter-bundle connections.