Entrapment of a Ventricular Lead and Guiding Catheter During Left Bundle Branch Area Pacing: A Stepwise Retrieval Approach

Entrapment of a ventricular lead and guiding catheter during left bundle branch area pacing is a rare but serious complication. A stepwise bailout strategy using bidirectional traction via femoral access and biopsy forceps enabled safe and successful retrieval without surgical intervention. An 81-year-old woman presented with dyspnea. She had a history of an anterior myocardial infarction treated with percutaneous coronary intervention and had undergone two surgical aortic valve replacements for severe aortic regurgitation. Medications included clopidogrel (75 mg/day) and ezetimibe (10 mg/day). A Holter electrocardiogram (ECG) showed paroxysmal atrioventricular (AV) block with a heart rate of 40 bpm, which was associated with dyspnea. On admission, physical examination revealed a heart rate of 83 bpm and blood pressure of 112/72 mmHg. Chest X-ray showed a cardiothoracic ratio of 53%. ECG indicated sinus rhythm, first-degree AV block, and complete right bundle branch block. Laboratory tests revealed a B-type natriuretic peptide (BNP) level of 45.9 pg/mL. Transthoracic echocardiography (TTE) demonstrated normal left ventricular contraction with a left ventricular ejection fraction of 69% and mild tricuspid regurgitation (TR). On the fourth hospital day, a pacemaker implantation with left bundle branch area pacing (LBBAP) was performed. A guiding catheter (C315HIS; Medtronic, USA) was introduced via the left precordial approach, and a ventricular lead (SelectSecure3830; Medtronic, USA) was advanced into the right ventricle (RV). Although the pacing threshold was not sufficiently satisfactory, a notch in lead V1 was confirmed, and the lead was positioned in the midseptal region of the RV (Figure 1A) and screwed into place. Because the pacing threshold remained unsatisfactory, the lead was repositioned. However, after a second screwing attempt with similarly unstable pacing thresholds, both the guiding catheter and the ventricular lead became entrapped and could not be withdrawn. Fluoroscopic images raised concern of a possible fracture of the distal tip of the guiding catheter (Figure 1B). An 18-Fr long sheath was inserted via the right femoral vein, through which an 8.5-Fr steerable sheath was advanced. Initial attempts to apply traction to the distal tip of the guiding catheter using a snare catheter and a pigtail catheter were unsuccessful. Therefore, biopsy forceps were introduced, and the distal tip of the guiding catheter was grasped with the forceps while traction was applied (Figure 2A). This maneuver successfully released the entrapment of the guiding catheter, although the ventricular lead remained entrapped (Figure 2B). Ultimately, no fracture of the distal tip of the guiding catheter was confirmed. A Judkins Left (JL) 1.0 catheter and a Radifocus guidewire were introduced via the right femoral vein. EN Snare Retrieval System (Hatch Medical L.L.C., USA) was introduced to capture the Radifocus guidewire, allowing traction to be applied from the inferior direction (Figure 3A). With simultaneous traction applied from above via the left precordial approach, the entrapment of the ventricular lead was successfully released. A small portion of the screw tip remained. Subsequently, the ventricular lead was positioned in the RV apex and the atrial lead in the right atrial appendage, completing the procedure (Figure 3B). Postoperative TTE showed no pericardial effusion, while the TR increased from mild to moderate (Figure 4A). A residual screw fragment was identified in the RV chordae (Figure 4B). However, the BNP level remained stable at 53.7 pg/mL, and no clinical worsening of heart failure was observed. The patient continues to be followed in the outpatient clinic. LBBAP is a physiological pacing method providing stable ventricular activation and favorable electrical performance 1. It is more feasible and effective for bradycardia patients than RV apical or His bundle pacing 2, and is safe though technically more challenging after open heart surgery 3. However, LBBAP has unique complications such as septal perforation, hematoma, and mechanical lead issues 4. In the MELOS registry of 2533 patients, lead helix entrapment occurred in about 0.43%, highlighting it as a rare but recognized complication 1. Seow et al. reported a unique bailout technique using electrocautery to safely disengage a trapped pacing helix during LBBAP, highlighting an effective management strategy for this emerging procedural complication 5. In contrast, Sakamoto et al. reported successful extraction of an entrapped ventricular lead using a laser sheath as a bailout strategy 6. In the present case, ventricular lead entrapment occurred during an attempt at LBBAP implantation, accompanied by suspected entrapment of the guiding catheter. In Figure 1B, the guiding catheter appears markedly twisted. This finding raises the possibility that the lead may have been screwed while involving tricuspid valve tissue or chordae tendineae, resulting in abnormal tension being transmitted to the guiding catheter. Although complications such as septal perforation, lead dislodgement, and septal hematoma have been reported with LBBAP, entrapment of the ventricular lead and guiding catheter is rare and not well described. Deep screwing into the interventricular septum, particularly in patients with prior cardiac surgery or an altered septal anatomy, may increase the risk of lead fixation-related complications and difficulty with withdrawal. In the present case, contrast injection was not performed prior to lead screwing. When resistance was encountered during lead withdrawal, a small amount of contrast was injected through the guiding catheter; however, it provided limited anatomical information. Soon after, the guiding catheter itself became entrapped, preventing further contrast injection. In retrospect, more comprehensive contrast imaging at the time of resistance might have clarified the anatomical relationship and the mechanism of entrapment. This case suggests that selective contrast injection may be useful when unexpected resistance or excessive torque is encountered during LBBAP. Previous reports have demonstrated that retained lead tips do not invariably result in adverse clinical outcomes. Kim et al. reported that among five patients with remnant RV lead tips after extraction for cardiovascular implantable electronic device infection, only one experienced recurrent infection, while the others remained free from major complications during long-term follow-up 7. These findings suggest that conservative management may be reasonable when the retained fragment is small, clinically stable, and not associated with ongoing infection or embolic phenomena. A key aspect of this case was the stepwise bailout strategy. Priority was given to releasing the entrapped guiding catheter to avoid catastrophic complications such as catheter fracture or embolization. Femoral venous access allowed the use of multiple tools, including biopsy forceps, snare catheters, and guidewires, enabling controlled bidirectional traction. This combined superior and inferior traction approach proved effective in releasing both the guiding catheter and the ventricular lead, although a small portion of the screw tip remained. Importantly, no pericardial effusion or clinical deterioration occurred, and the patient remained hemodynamically stable despite a mild-to-moderate increase in TR. This case highlights several important lessons. First, while LBBAP is increasingly performed, operators should recognize that excessive resistance during lead withdrawal may indicate entrapment, and forceful traction should be avoided. Importantly, excessive traction may lead to guiding catheter entrapment in addition to lead entrapment, as demonstrated in this case. In addition, if suboptimal pacing thresholds or instability are observed during prescrew mapping, operators should consider the possibility that the lead may be interposed not within the ventricular septal myocardium but between intracardiac structures such as the chordae tendineae. Second, early consideration of a bailout strategy using femoral access can provide additional maneuverability and improve procedural safety. As in the present case, biopsy forceps may be useful for grasping the distal tip of a guiding catheter. Finally, leaving a small residual lead fragment may be an acceptable option when complete extraction carries a higher risk of structural damage, provided that careful follow-up is ensured. In conclusion, ventricular lead and guiding catheter entrapment represent extremely rare but clinically important complications of LBBAP. Awareness of this potential pitfall and familiarity with bailout techniques, including bidirectional traction via femoral access and precise grasping with biopsy forceps, could contribute to the safe performance of contemporary LBBAP. We are grateful to the members of our laboratory for helpful discussions and comments on the manuscript. The authors have nothing to report. The authors have nothing to report. The authors have nothing to report. Written informed consent was obtained from the patient. The authors declare no conflicts of interest. Research data are not shared.