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Learning Curve for Left Bundle Branch Area Pacing – the Experience of a Romanian Academic Center

Catalin Pestrea
Catalin Pestrea
, 
Alexandra Gherghina
Alexandra Gherghina
, 
Irina Pintilie
Irina Pintilie
 and 
Florin Ortan
Florin Ortan
   | May 03, 2022
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Article Category: Original Article
Published Online: May 03, 2022
Page range: 327 - 334
DOI: https://doi.org/10.47803/rjc.2021.31.2.327
Keywords
© 2021 Catalin Pestrea et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.

Figure 1

The „ideal” site to start penetrating the septum is where pacing results in a „W” pattern in V1 and polarity discordance in DII vs. DIII and aVL vs. aVR. (His d channel records the electrograms from the pacing lead tip).
The „ideal” site to start penetrating the septum is where pacing results in a „W” pattern in V1 and polarity discordance in DII vs. DIII and aVL vs. aVR. (His d channel records the electrograms from the pacing lead tip).

Figure 2

A Qr pattern in V1 indicates that the lead tip has reached the left side of the septum and the screwing should stop (His d channel records the electrograms from the pacing lead tip).
A Qr pattern in V1 indicates that the lead tip has reached the left side of the septum and the screwing should stop (His d channel records the electrograms from the pacing lead tip).

Figure 3

The lead is placed deep into the septum where a left bundle potential is recorded (black arrow). Pacing at this site results in a narrow QRS complex with a RBBB morphology and a short LVAT, similar to the one in sinus rhythm (His d channel records the electrograms from the pacing lead tip).
The lead is placed deep into the septum where a left bundle potential is recorded (black arrow). Pacing at this site results in a narrow QRS complex with a RBBB morphology and a short LVAT, similar to the one in sinus rhythm (His d channel records the electrograms from the pacing lead tip).

Figure 4

Left anterior oblique (LAO) fluoroscopy image. Contrast injected through the sheath delineates the right side of the septum and gives an estimate of the depth of penetration of the pacing lead (black star). Another pacing lead was placed for back-up pacing at the RV apex (white star).
Left anterior oblique (LAO) fluoroscopy image. Contrast injected through the sheath delineates the right side of the septum and gives an estimate of the depth of penetration of the pacing lead (black star). Another pacing lead was placed for back-up pacing at the RV apex (white star).

Figure 5

Parasternal short axis echocardiographic view showing the lead tip (white arrow) reaching the LV endocardium.
Parasternal short axis echocardiographic view showing the lead tip (white arrow) reaching the LV endocardium.

Figure 6

QRS duration before and after the procedure.
QRS duration before and after the procedure.

Figure 7

Comparison of the fluoroscopy time between the first and the second half of the procedures.
Comparison of the fluoroscopy time between the first and the second half of the procedures.

Figure 8

Differential extrastimulus pacing to demonstrate nonselective left bundle branch capture. After a drive train of 8 beats at 600 ms, an early extrastimulus (black star) results in a similar morphology to the one in the driving train. An even earlier extrastimulus (black arrow) results in a different morphology (more obvious in DII, DIII and V1) as the refractory period of one structure is encountered (see text for details).
Differential extrastimulus pacing to demonstrate nonselective left bundle branch capture. After a drive train of 8 beats at 600 ms, an early extrastimulus (black star) results in a similar morphology to the one in the driving train. An even earlier extrastimulus (black arrow) results in a different morphology (more obvious in DII, DIII and V1) as the refractory period of one structure is encountered (see text for details).

Patient and procedural characteristics

Patient characteristics Nr. (%)
Age 65.9 ± 12.7 years
Male sex 12 (60)
Mean Ejection Fraction (%) 44±16
Pacing indications
AV block in sinus rhythm 14 (65)
Cardiac resynchronization therapy 6 (30)
Slow conducting atrial fibrillation 1 (5)
QRS aspect
Normal 9 (45)
Left bundle branch block (LBBB) 10 (50)
Right bundle branch block (RBBB) 1 (5)
Procedural characteristics Nr. (%)
Device implanted
Dual chamber pacemaker 18 (90)
Single chamber pacemaker 1 (5)
CRT-D device 1 (5)
Procedural parameters
Pacing threshold (V/0.4 msec) 0.56±0.2
Detection (mV) 10.3±3.9
Impedance (Ohm) 684.9±112.2
Fluoroscopy time (min) 13.8±8.5
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Medicine, Clinical Medicine, Internal Medicine, Cardiology, Pediatrics and Juvenile Medicine, Paediatric Cardiology, Surgery, Cardiac Surgery
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