My preferred approach to left bundle branch pacing: Lumenless leads

Figures

• 

  Figure 1. Lumenless lead and delivery sheaths. A: The lumenless lead has an open helix of 1.8 mm length with interelectrode distance of 9 mm. B: The lumenless lead has an inner conductor surrounded by insulators and coiled outer conductor. C: The C304 His sheath is a deflectable one with outer diameter of 8.4F and can be helpful in difficult cases. D: The C315 His sheath has fixed 2 curvatures for facilitating entry into the right ventricle and facing toward the septum. Reprinted with permission from Medtronic.

• 

  Figure 2. PVC morphology during LBBP. A: Premature ventricular complexes during left bundle branch pacing with lumenless lead. Note the change in premature ventricular complex (PVC) morphology from QS to qR as the lead traverse from right to the left side of the septum. The last generated PVC labeled as M-beat had an M pattern in lead V1 with a slurred S-wave in lead V6. The morphology of the M-beat mimicked a selective left bundle branch captured beat. B: Nonselective-to-selective capture transition noted at a near-threshold output value. LBBB = left bundle branch block.

• 

  Figure 3. Septal perforation during left bundle branch pacing with lumenless lead. A: Note the absent current of injury along with QS pattern in the unfiltered unipolar electrogram (LB-U) during complete perforation into the left ventricular cavity. B: After repositioning the same lumenless lead at a different site, an unfiltered electrogram showed significant current of injury along with sharp left bundle potential. His-d = His distal; His-p = His proximal; LB-F = left bundle filtered; LB-U = left bundle unfiltered; RVA = right ventricle apex.

• 

  Figure 4. Lumenless pacing lead extraction. A: Lead extracted after 2 years en masse without damaging the helix. B: Echocardiography showing no significant septal defect after extraction of 1.4-mm sized lumenless lead. Note the position of the new lumenless lead at the midseptum reaching left ventricular subendocardium.