EHRA clinical consensus statement on conduction system pacing implantation: executive summary. Endorsed by the Asia-Pacific Heart Rhythm Society (APHRS), Canadian Heart Rhythm Society (CHRS) and Latin-American Heart Rhythm Society (LAHRS)

Figure 1. Synopsis of CSP and related pacing modalities. Modified with permission from Filip Plesinger and from Jastrzebski et al.1

Figure 2. ECG transitions with decrementing pacing output, and morphological features to diagnose his bundle capture. Adapted with permission from Burri et al.3

Figure 3. Insertion site for LBBA pacing. In a 30° RAO view, contrast is injected through a sheath delineating right atrial and ventricular anatomy as well as tricuspid valve leaflets. The summit of the tricuspid annulus indicates the approximate His bundle position. The red arrow indicates an imaginary line that connects the tricuspid annulus summit/His bundle with the RV apex, which serves as a guide for placing the lead. Successful pacing sites can be localized within a sector (indicated in yellow) located 15–35 mm away from the tricuspid annulus summit and at an angle of −10° to 30°, as described by Liu et al.16

Figure 4. Left panel: LAO view for orienting the lead 10–40° (most often 20–30°) with respect to the horizontal plane for perpendicular septal penetration.

Figure 5. Lead behaviour during penetration of the septum with LBBAP. Both drill and screwdriver effects can result in perforation.

Figure 6. Algorithm for confirming conduction system capture with LBBAP. Some of the steps may be skipped according to operator preference, experience or feasibility to perform particular measurements/maneuvers.

Figure 7. Device configuration for CSP according to device indication, underlying rhythm (i.e. requirement for an atrial lead), presence on an additional ventricular lead. In all cases with a CSP lead plugged to the RV port, adequate sensing must be ensured. Not shown here are additional configurations with Y-adapters.1 Additional ventricular lead may be indicated for ICD therapy, backup pacing, adequate ventricular sensing, or CRT optimization.2 The LV lead is plugged to the RV port in case the CSP lead does not provide proper sensing (atrial or His potential oversensing and ventricular undersensing are issues that may be encountered with HBP). * DF-1 ICD lead may also be used; # IS-1 LV lead may also be used.