Is it feasible to perform permanent left bundle branch area pacing, guided only by an electroanatomical mapping system? Proposal of a zero-fluoroscopy approach

Figures

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  Figure 1. Left (LAO, on the left panel) and right (RAO, on the right panel) anterior oblique projections of the electroanatomical map obtained with the diagnostic decapolar catheter, using the Abbott EnSite Precision mapping system (Abbott Inc, St Paul, MN). In the central panel, the His bundle potential is shown (green electrogram), together with baseline spontaneous QRS complex morphology. Yellow dots indicate His bundle cloud. Color-coded structures: yellow = superior vena cava; lilac = inferior vena cava; gray = right atrium; green = right atrial appendage; red = coronary sinus; purple = right ventricle; blue = right ventricular outflow tract.

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  Figure 2. A: Paced QRS morphology at the initial screwing point on the right ventricular surface of the septum; a “W” pattern in V1 is seen. B: Paced QRS morphology at the end of screwing, with nonselective left bundle branch capture; stimulus-to-R-wave peak time in lead V6 is 64 ms. C: Programmed unipolar tip stimulation of the left bundle branch area lead, showing an abrupt change in paced QRS morphology at the coupling interval of 300 ms, suggesting transition to left ventricular septal myocardial capture (thus confirming nonselective left bundle branch capture obtained).

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  Figure 3. A, B: Right anterior oblique projection (RAO, A) and a cranial view of the left anterior oblique projection (LAO, B) of the electroanatomical map, showing the final positions of the implanted atrial and left bundle branch area pacing lead tips (RA and LBBAP, respectively), in bipolar visualization, together with the bipolar electrogram of the LBBAP lead, showing a small sharp potential anticipating local ventriculogram of 15 ms. Yellow dots indicate His bundle cloud. Color-coded structures: yellow = superior vena cava; lilac = inferior vena cava; gray = right atrium; green = right atrial appendage; red = coronary sinus; purple = right ventricle; blue = right ventricular outflow tract.

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  Supplemental Figure 1Panel A: the revolving adapter used during the procedure is shown; it was obtained by cutting away the alligator clip and wrapping the resulting wires around the cathode pin of the lead, in order to allow continuous unipolar connection of the tip during screwing maneuvers. Panel B: the single-shot (duration less than 1 s) X-Ray evaluation of the leads, before connecting them to the dual chamber pacemaker, showed an adequate slack for both.