Bachmann's bundle pacing implantation using a P-wave amplitude-guided approach: a single-center experience

Background Bachmann’s bundle pacing (BBp) may suppress atrial fibrillation (AF) incidence and persistence. The Bachmann’s bundle (BB) area is located at the level of the sinus node, corresponding to the junction between the superior vena cava (SVC) and the right atrium (RA). We identified the SVC–RA junction by detecting an abrupt change in local atrial electrogram amplitude recorded at a pacing lead and implanted the lead in the BB area. Purpose To evaluate the feasibility, safety, and short-term outcomes of a P-wave amplitude-guided implantation strategy for BBp. Methods We retrospectively included 50 patients who underwent dual-chamber pacemaker or implantable cardioverter-defibrillator implantation with attempted BBp between September 2023 and December 2024. The SVC–RA junction was identified by a "jump-up" in local atrial electrogram amplitude recorded at the lead tip. The pacing lead was screwed just below this point. Results Atrial septal lead implantation was achieved in all 50 patients, with successful BBp (meeting ECG criteria) in 44 (88%). The mean mapping time was 134.5 seconds. Immediately after screwing, the mean capture threshold was 1.86±1.00 V at 0.4 ms, improving to 0.834±0.315 V by the end of the procedure. During a 6-month follow-up, pacing parameters remained stable, with no lead dislodgement, pericardial effusion, or device-related infection. Five patients developed paroxysmal AF; no deaths or major complications occurred. Conclusion BBp using the lumenless pacing lead and delivery catheter, guided by a P-wave amplitude–based strategy, is safe, feasible, and reproducible. BBp may be preferable to conventional right atrial appendage pacing.