Left bundle branch area pacing in dextroversion

Figure 1. Cardiac silhouette created with electroanatomic mapping (CARTOSOUND, Biosense Webster, Irvine, CA) demonstrating dextroversion: rightward rotation of the heart with normal orientation of the chambers. AP = anteroposterior; LAO = left anterior oblique; RAO = right anterior oblique.

Figure 2. Presenting ECG demonstrating sinus rhythm with atrioventricular nodal Wenckebach. AVB = atrioventricular block; ECG = electrocardiogram; HR = heart rate; QRSD = QRS duration; QTc = corrected QT.

Figure 3. Chest computed tomography demonstrating rotation of the heart such that the left ventricle is immediately retrosternal and the apex is directed rightward. V1’ represents the lead location chosen to mimic the traditional V1 location for left bundle branch area pacing. L = left; R = right.

Figure 4. Electrocardiogram performed during implantation. Lead V3 was positioned between the left scapula and spine to mimic V1. Note the qR pattern in V1’ consistent with left bundle branch area pacing. All other leads were in standard locations.

Figure 5. Final lead position on fluoroscopy. Note that, in the RAO image, the apex of the heart is directed toward the viewer, mimicking a traditional LAO view. The LAO image is essentially a reversed RAO image such that the apex is toward the left of the image. LAO = left anterior oblique; RAO = right anterior oblique.

Figure 6. Final chest radiograph. L = left.

Figure 7. Final ECG demonstrating sinus tachycardia with left bundle branch area pacing. Lead “V1 Inverted” has been added demonstrating a Qr pattern consistent with left bundle branch area pacing. ECG = electrocardiogram; HR = heart rate; QTc = corrected QT; QRSD = QRS duration.