Conduction System Pacing With Stylet Driven Leads: A Step-By-Step Guide to Implant.

In recent years, there has been a surge of interest in strategies to perform conduction system pacing (CSP). Of these, left bundle branch area pacing (LBBAP) has rapidly gained popularity as the preferred approach to perform CSP due to favorable pacing thresholds and greater perceived ease of implant. The majority of initial descriptions of LBBAP has focused on use of lumenless pacing leads. More recently, stylet-driven leads have increasingly been utilized during CSP, and may have shorter procedure and fluoroscopy times. The purpose of this article is to provide a practical description of LBBAP with stylet-driven leads, with specific attention to tips and procedural nuances to achieve a successful implant. We focus here on a "step-by-step" approach to CSP utilizing stylet-driven leads. For consistency, we have focused on the Boston Scientific Ingevity+ lead and Site Selective Pacing Catheter (SSPC) family of sheaths. Similar techniques can be also used with other stylet-driven including Abbott UltiPace and CPS Locator 3D family of catheters or the Biotronik Solia S and Selectra 3D family of catheters. The steps cover preprocedural planning and vascular access, sheath selection and placement, use of ventriculography, lead delivery and recording, sheath removal, and trouble-shooting. Stylet-driven leads are now a feasible option for patients undergoing implantation of a left bundle branch area pacemaker with overall technique which is similar to lumenless leads with a few key differences that can be learned relatively quickly and improve overall success rate.