Lumenless and Stylet-Driven Leads for Left Bundle Branch Area Pacing: Materials, Techniques, Benefits, and Trade-Offs of the Two Approaches

Figures

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  Figure 1. Panel (A): Septal mapping and W sign in V1 during pacing at 100 mm/s (yellow circle); transition during septal penetration, from W sign to rsR’ on V1 (red circle). Panel (B): Same ECG reproduced at 25 mm/s. Panel (C): Non selective LBBPa at 2.5 V × 0.4 ms without isoelectric line (yellow circle); selective capture of LBBPa at lower output (red circle). Panel (D): LBBPa pacing ECG at 25 mm/s.

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  Figure 2. Medtronic materials are shown. In Panel (A), SelectSecure™ 3830 features are listed. In vitro and in vivo analysis assessed the lead’s durability under extreme bending conditions, predicting a 10-year fracture rate of 0.02% [6]. The lower Panel (B) shows Medtronic C315 fixed curve delivery sheaths and the deflectable C304 delivery sheath.

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  Figure 3. Biotronik delivery sheaths are shown in Panel (A,B) with three different 3D-shaped curves to accommodate different anatomies. Panel (C,D) show an assembled delivery with a stylet-driven Solia S lead. The green locking tool allows an easier helix deployment into the septum. Panel (E) shows Biotronik slitter over the lead.

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  Figure 4. Panel (A). Abbott delivery and helix locking tool are shown. Panel (B): Tendril™ (Abbott) helix deployment in LAO projection. In this case, RA lead can be temporarily placed in RV septum as a backup lead during LBBPa lead positioning. Panel (C): Final position of the leads in LAO projection (left panel) and Ap view (right panel).

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  Figure 5. Panel (A): Boston Scientific offers three different 3D fixed curved delivery sheaths. SSPC3 Extended Hook Curves 2 and 3 are the most used. Panel (B): In panel B, an AP projection is shown on the left. Deep septal penetration is achieved by outer body torquing. On the right is an RAO projection of the same patient. Panel (C): Different curves from Site Selective Pacing Catheter (SSPC family). SSPC1 is a “C-shape” designed for RA septal locations. SSPC2: “Multipurpose” designed for RA and RV septal locations. SSPC3 is the “Extended hook” thought for septal locations like LBBPa. SSPC4 was designed for right-sided venous access to RA septal locations.

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  Figure 6. Panel (A) shows a customized locking tool for the Ingevity + catheter lead. Step 1: Cut the lead cap at ⅔ of the longer tail, as shown in the figure. Step 2: Insert it into the lead. Step 3: The insert tool is pushed under the cut tail of the cap and over the IS1 tip. The customized sleeve locks the inner coil and prevents helix retraction. Step 4: Insert the desired stylet. Panel (B) shows an assembled lead with the customized locking tool.

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  Figure 7. Comparison between SDL and LLL.