Left bundle branch area pacing with stylet-driven pacing leads: implantation technique
International Journal of Arrhythmia volume 24, Article number: 12 (2023)
Traditional right ventricular apical pacing can cause electrical–mechanical dyssynchrony. Therefore, physiological conduction system pacing was considered and became the reason for developing His bundle pacing (HBP). Recently, left bundle branch area pacing (LBBAP) has been implemented, which overcomes the shortcomings of HBP. Most initial large LBBAP studies reported that LBBAP was achieved through a lumenless pacing lead (LLL) with a fixed helix design; however, it is unavailable in Korea. LBBAP delivery sheaths using a conventional standard stylet-driven pacing lead (SDL) with an extendable helix design are currently available in Korea. In this review, we describe the methods and procedural skills required to perform the LBBAP using conventional SDL.
LBBAP has emerged as a new physiological CSP modality and has shown a stable and lower capture threshold and achieved a similarly paced QRS duration compared to HBP. It has also demonstrated stable early outcomes for feasibility and safety with a high success rate. Furthermore, the application of LBBAP has recently been extended to a resynchronization strategy. The LBBAP with SDL requires different handling and lead preparation owing to differences in lead and helix designs. Reported procedure-related acute complications of LBBAP include septal perforation during the procedure, pneumothorax, pocket infection, pocket hematoma, and lead dislodgements occurring during follow-up.
LBBAP with conventional SDL has similar implant success rates, procedural safety, and pacing characteristics as LBBAP with LLL. However, LBBAP with SDL requires different handling and lead preparation from that of LLL owing to the differences in the lead and helix designs.
Cardiac pacing is an essential therapeutic strategy for bradyarrhythmia. Although cardiac pacing has been performed traditionally at the right ventricular (RV) apex, it causes electrical and mechanical dyssynchrony, which can lead to pacemaker-induced cardiomyopathy and heart failure [1,2,3]. Consequently, physiological conduction system pacing has emerged, and His bundle pacing (HBP) has been considered the most optimal physiological conduction system pacing (CSP) [4, 5]. However, HBP has some limitations, including difficulty identifying the precise location of the His bundle due to its very small area and sometimes high pacing output [6, 7]. Moreover, HBP may not be helpful when the block site is at the infra-Hisian level or in the case of a proximal left bundle branch block (LBBB). Thus, left bundle branch area pacing (LBBAP) that overcomes the shortcomings  of HBP has been implemented as an alternative method for physiological CSP [8,9,10,11].
LBBAP was achieved early in its revolution using a lumenless pacing lead (LLL) with a fixed helix design, which is unavailable in Korea. However, it is known that LBBAP can be conducted using a conventional standard stylet-driven pacing lead (SDL) with an extendable helix design by utilizing the sheath-guided implantation method [12,13,14]. Currently, LBBAP is being performed stably in Korea using SDL.
In this review, we describe the methods and detailed procedural skills required for LBBAP implantation using conventional SDL.
Paradigm shift in ventricular pacing
Since the implantable pacemaker was used in humans by C. Walton Lillehei in 1958, artificial pacemakers have become the basis of bradycardia treatment . For approximately 50 years, the standard site for cardiac pacing has been the RV apex. Conventional RV apical pacing reduces symptoms and improves the quality of life, exercise capacity, and survival in patients with sick sinus syndrome and atrioventricular block [16, 17]. However, in some patients, it adversely affects the structure and function of the heart and can cause heart failure (HF) [1,2,3].
In 2000, Deshmukh et al. introduced permanent HBP to treat bradyarrhythmia . They reported the role of HBP in tachycardia-induced cardiomyopathy in patients with atrial fibrillation. Afterward, meaningful studies on HBP conducted between 2006 and 2011 explained the need for CSP and demonstrated its effectiveness and safety [19,20,21]. However, these HBPs had some limitations. HBP implantation in an appropriate location is difficult, and the success rate is low, especially in patients with QRS prolongation; even when successful, the pacing capture threshold is often high and requires a high pacing output [6, 7].
Amidst this, LBBAP, proposed by Huang et al. , has emerged as a new physiological CSP modality. LBBAP has shown a stable and lower capture threshold and achieved a similarly paced QRS duration compared to HBP . It has also demonstrated stable early outcomes for feasibility and safety with a high success rate [10, 23]. LBBAP has currently become a widely used CSP as stable mid- and long-term outcomes have been reported over the years [9, 24, 25]. Furthermore, the application of LBBAP has recently been extended to a resynchronization strategy (Fig. 1) [26,27,28,29,30,31].
Definition of left bundle branch pacing (LBBP)
Generally, LBBAP includes deep septal pacing, nonselective LBBP, and selective LBBP. The definitive definition of LBBP is more specific than LBBAP, and we have summarized the definitions of LBBP reported in previous studies.
The success of LBBP is confirmed by observing left bundle branch (LBB) potential directly in the intracardiac electrogram and paced surface 12-lead electrocardiogram (ECG). The generally accepted characteristics of the intracardiac and surface electrocardiograms in LBBP are as follows:
LBB potential (LBB-V interval of 15–35 ms).
In patients with non-LBBB during intrinsic rhythm, a sharp high-frequency deflection called LBB potentials is recorded from the pacing lead, with the potential to ventricle interval of 15–35 ms [32,33,34]. LBB potential to left ventricular activation time (LVAT) interval is equal to the stimulus to LVAT (Stim-LVAT) interval in V5–V6 (± 10 ms) .
Stim-LVAT as measured in V5–V6 < 75–85 ms.
Stim-LVAT is defined as the interval from the pacing stimulus to the peak of the R-wave and is often used to reflect the lateral precordial myocardium depolarization time in leads V5–V6. Stim-LVAT that shortens abruptly with increasing output or remains the shortest and constant at both low and high outputs suggests LBB capture. Meanwhile, a fast left ventricular (LV) peak activation time of approximately 80 ms is indicative of fast activation propagation throughout the specialized LV conduction fascicules of the LBB [32, 33].
The transition from nonselective LBB capture to selective LBB capture and from nonselective LBB capture to left ventricular septal capture at near-threshold output indicates LBB area pacing.
QRS morphology change by the programmed stimulation from pacing lead .
Implantation of left bundle branch area pacing
Lumen-less pacing lead versus stylet-driven pacing lead
Most large cases of LBBAP have been exclusively performed using an LLL with a fixed helix design and a pre-shaped sheath dedicated to this lead [8, 10, 36]. Because the LLL has no inner lumen, the lead body diameter is relatively as small as 4.1 Fr and is an isodiametric lead with a fixed helix (1.8 mm length) design. LLL does not have a stylet; therefore, a dedicated delivery sheath is required. There are two types of sheath: fixed double curve (C315 His, Medtronic Inc., Minneapolis, USA) and deflectable curve (C304 and C304 His, Medtronic Inc., Minneapolis, USA). Meanwhile, the only commercially available LLL is the Select Secure 3830 pacing lead (Medtronic Inc., Minneapolis, USA).
Moreover, it has been reported that LBBAP using a standard stylet-driven lead is available [12,13,14]. Because SDL has an inner lumen for stylet insertion, the lead body diameter is larger than that of LLL with > 5.5 Fr. The helix has an extendable–retractable design (1.8–2.0 mm fully extended length). Because the SDL has a larger diameter than the LLL, the electrically active helical surface has a larger SDL. Commercialized SDLs include Solia S pacing lead (Biotronik, SE & Co., Berlin, Germany), Ingevity pacing lead (Boston Scientific Inc., Marlborough, USA), and Tendril 2088TC pacing lead (Abbott, Inc., Chicago Illinois, USA). Additionally, the SDL is delivered through a sheath because it properly targets the pacing site and maintains sufficient backup during lead implantation. Sheaths approved for SDL implantation are Selectra 3D pre-shaped sheath (Biotronik, SE & Co., Berlin, Germany), SSPC pre-shaped sheath (Boston Scientific Inc., Marlborough, USA), and Agilis HisPro deflectable sheath (Abbott, Inc., Chicago, Illinois, USA). The sheath size is 7–9 F and has a side port; hence, the contrast medium can be used if necessary.
Lead preparation of SDL
The LBBAP with SDL requires different handling and lead preparation owing to differences in lead and helix designs. Here, we describe a procedure using the SDL with Solia S pacing lead. The lead preparation was performed as previously described [12,13,14]. The Solia S pacing lead (Biotronik, SE & Co., Berlin, Germany) is a 5.6-Fr-sized SDL with an extendable helix design. The lead body comprises inner and outer coils, and the distal of the inner coil is connected to the helix and proximal to the rotating pin of the pacing lead. When positioning is attempted with the helix out, the lead hangs better, and the parameters are more accurate during pace mapping, thus extending the helix before positioning the lead in the LBBAP area. The lead body is prepared by exposing the extendable screw by turning the outer pin 10–12 times clockwise (Fig. 2A), followed by an additional turning of the outer pin five times clockwise using the standard stylet guide tool delivered with the lead to avoid partial unwinding of the extendable helix (Fig. 2B). The helix may be extended before the lead is placed in the sheath or after the lead is placed in the sheath; however, in the former case, the extended helix may be damaged by the check-valve of the sheath. Therefore, it is recommended to use a transvalvular insertion tool when inserting the lead into the sheath (Fig. 2C).
In the case of the sheaths produced by the companies Biotronik SE & Co. and Boston Scientific Inc., since there are sheaths that are the pre-shaped type and a fixed form, the selection of the sheath before the procedure can affect the result of the procedure outcome. The Biotronik SE & Co. sheath has three types of lengths and three different sizes of curves, and one of a total of nine types of the sheath was selected in a previous study. The initial choice was to select a mid-length, mid-size curve (Selectra 3D-55-39) that was more suitable for the size of the heart. Consequently, the sheath used changes to a smaller or larger size depending on the size of the patient’s heart. For the Boston Scientific Inc. sheath, one of the four types of sheaths with the same length and different curve shapes was selected in a previous study. The initial attempt was to use a sheath with a general curve (SSPC2), which could be changed to a more C-shaped or an extended hook depending on the shape of the heart.
Finding the sweet spot for LBBP
To determine the initial screwing position, the methods of exploring the LBB area based on His area and determining the position using the nine-partition method are generally used [35, 37]. The method based on His area is as follows: After confirming His area with a catheter, place the lead tip at 1–2 cm toward the RV apex from His area in the right anterior oblique (RAO) view and perpendicular to the septum in the left anterior oblique (LAO) view, as described in previous studies [35, 38]. Particularly, by positioning a His/RV catheter in the RV and His area, His potential mapping as a landmark and ventricular backup pacing are possible. Although this method has been reported to have a high success rate, it cannot be applied to patients without signs. The nine-partition fluoroscopic method would be useful if His potential is not visible . In this method, an RAO fluoroscopic image of the ventricle is divided into nine sections and two specific partitions (high and median septum middle areas) as LBB areas, and the leads were placed by targeting these areas. This method may take longer because the target site is wider than that of the method using the area as a landmark; however, this method is also reported to have a high success rate [39, 40].
Lead penetration and fixation
To maintain lead tension, screw the pacing lead interventricular septum from the right side to the left side while ensuring the stylet is inserted fully. Subsequently, advance the pacing lead by fast rotation 5–10 times to overcome the septal resistance, and keep the stylet in pacing lead until the final position is reached . Sudden decrease in lead impedance, sensed R‐wave amplitude, and/or loss of capture indicates that the helix of the lead has entered the chamber of the left ventricle, for example, LV perforation; if this occurs, the pacing lead should be rotated back and relocated.
Confirmation of LBB capture
Pacing the right side of the IVS produces an ECG QRS configuration with an LBBB pattern. With the advancement of the lead, the LBBB pattern gradually diminishes until an ECG QRS configuration with an RBBB configuration in lead V1 is observed, suggesting the site of pacing at the LBB. At this point, during programmed stimulation, a fast peak LV activation time in leads V5–V6 of approximately 75–80 ms should be noted, which demonstrates the transition from deep ventricular septal pacing to LBBAP. When the pacing lead is near or at the LBB, an LBB potential can be recorded [37, 41]. After confirming the LBBP, remove the sheath using a slitter with the stylet pulled back slightly. Following the completion of the procedure, bipolar pacing parameters should be tested because the local ventricular EGM for distinguishing between selective and nonselective LBBP may be unclear on the unipolar paced lead. The above procedure steps are summarized in Fig. 3, and examples of intracardiac electrograms during LBBAP are summarized in Fig. 4.
Reported procedure-related acute complications of LBBAP include septal perforation during the procedure, pneumothorax, pocket infection, pocket hematoma, and lead dislodgements occurring during follow-up [42, 43]. Particularly, attention should be paid to the septal perforation occurrence in the case of the LBBAP procedure, unlike in the case of other cardiac implantable electronic devices. Generally, a method of continuously checking the drop (< 500 ohms) of lead impedance is used to detect septal perforation [35, 41], and recently, it has been reported that the unipolar pacing parameters (unipolar electrograms of < 450 ohms) and electrograms (unfiltered unipolar electrograms of QS or RS/rS) have high specificity and sensitivity to identify septal perforation in patients who undergoing LBBAP . This monitoring process not only affects the acute success rate of the procedures but is also a way to avoid long-term unfavorable outcomes.
LBBAP with conventional SDL has similar implant success rates, procedural safety, and pacing characteristics as LBBAP with LLL. Owing to the differences in the lead and helix designs, LBBAP with SDL requires different handling and lead preparation from LLL. However, the method of exploring the target site and confirming the LBBP was not significantly different from the procedure using LLL.
Availability of data and materials
The data underlying this article will be shared upon reasonable request from the corresponding authors.
Conduction system pacing
His bundle pacing
Left anterior oblique
Left bundle branch
Left bundle branch area pacing
Left bundle branch block
Lumen-less pacing lead
Left ventricular activation time
Right anterior oblique
Stimulus to left ventricular activation time
Stylet-driven pacing lead
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Yu, GI., Kim, TH., Yu, H.T. et al. Left bundle branch area pacing with stylet-driven pacing leads: implantation technique. Int J Arrhythm 24, 12 (2023). https://doi.org/10.1186/s42444-023-00095-1