Synchronized left anterior/posterior fasciculars pacing - a modified strategy for difficult left ventricular lead implantation during CRT-D: A case report

Cardiac resynchronization therapy - defibrillator (CRT-D) is an effective treatment for ischemic heart failure (HF). But, it is a tricky challenge for left ventricular lead implantation difficulties during CRT-D. We report an ischemic cardiomyopathy patient with complete right bundle branch block (cRBBB) underwent CRT-D. During the implantation, the left anterior fascicular (LAF) region pacing was not ideal, and the implantation of left ventricular lead in lateral posterior or posterior wall was difficult. Then, leads were changed to be implanted into anterior septal region (near the LAF) and posterior septal region (near the LPF) from right ventricle, respectively. Synchronized pacing of LAB and LPB was performed to replace the pacing of left bundle branch region and left ventricular lateral posterior wall. Then, the QRS duration was shortened from 160ms to 100ms. During one month in follow-up, the patient's quality of life was good and the pacing parameters were stable. This case illustrates a technically feasible, hypothesis-generating bailout approach for selected patients when conventional coronary sinus left ventricular lead placement and standard conduction system pacing are unsuccessful.