A MacGyvering way to left bundle branch area pacing: Using the modified V1/V6 leads connected to the pacing system analyzer

Figures

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  Figure 1. Novel limb lead repositioning (left) on the chest wall allowing the generation of pseudo-V1 and pseudo-V6 electrocardiograms (ECG) on the programmer (middle) correlating with the 12-lead ECG (right). The left panels show the generation of pseudo-V1 (top) with the Medtronic system, while the lower left panel shows visualization of pseudo-V6 and calculation of the left ventricular activation time. The middle panel shows the measured left ventricular activation time from the pacing system analyser (PSA). The treadmill test machine was used for visualization of screw beats during pacing. The arrows connect the novel lead positioning on the chest wall (black/ red circles) to the PSA to V1/V6 on the 12-lead ECG (yellow arrows). Simultaneous ECG is shown in the right panel, showing the correlation of pseudo-V1 and pseudo-V6 on the PSA with V1 and V6 on the 12-lead standardized ECG.

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  Figure 2. (Left) The lead positioning with the St Jude Abbott PSA. (Middle) The pacing system analyzer (PSA) screen during lead screw in demonstrating dynamic impedance monitoring, changes in paced electrocardiographic (ECG) morphology, and screw beats. (Right) The corresponding treadmill test ECG during the implantation. The red arrows connect the novel lead positioning on the chest wall to the PSA. The yellow rectangle insert shows transition from the left bundle branch block morphology to right bundle branch block during continuous pacing during screwing of the lead. The blue oval insert shows screw beats prior to left posterior fascicle capture during screwing. LA = left arm.

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  Figure 3. Bland-Altman plot to show agreement between the measurement of left ventricular activation time (LVAT) on the pacing system analyzer (PSA) and the 12-lead electrocardiogram (ECG) (left) and between the measurements of QRS duration on 12-lead ECG and PSA (right). All the data points lie within ±1.96 SD of the mean difference, indicating excellent agreement between 2 measurement techniques for both LVAT and QRS duration. ICC = intraclass correlation coefficient.