Left bundle branch area pacing in congenital heart disease

Figures

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  Figure 1. Sheath reshaping techniques for complex anatomy; all reshaping is performed with the dilator in situ to prevent sheath kinking or crush. (A) Exaggerated primary curve (left) for dilated RVs compared with ‘stock’ C315H. (B and C) Medtronic MPR CS guide with the proximal 12 cm cut off. (D) C315H sheath placed through a cut off MPR for extra sheath support (in cases of dilated RA). (E) Additional curve on MPR to address combined RA and RV dilation. (F) Complete reversal of the primary curve (left) for TGA with atrial-switch or dextrocardia anatomy.

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  Figure 2. Left bundle branch area pacing in a patient with TGA with Mustard’s repair and stented systemic venous baffles. (A) fluoroscopic view in PA projection showing a multielectrode catheter (HD grid) for mapping of left bundle branch potentials with the 3830 SelectSecure lead within a (reshaped) C315H sheath and a quadripolar catheter for backup pacing in the sub-pulmonary left ventricle. (B) LAO projection at 30° showing contrast injection during lead tunnelling. (C) Baseline ECG showing complete AV block. (D) Post-procedure paced ECG with QRS duration of 160 ms. LAO, left anterior oblique; PA, posteroanterior.

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  Figure 3. Left bundle area pacing in a patient with dextrocardia. (A) Right ventriculogram in LAO projection at 20° to identify anatomical landmarks. (B) Tunnelling process monitored in RAO 20°. The primary curve of the sheath was reversed to face the septum. (C) Baseline ECG showing sinus rhythm with negative QRS in V4-V6, I and aVL, typical of dextrocardia with QRS duration of 96 ms. Pacing indication was 6 s sinus pauses. (D) Post-procedural ECG showing QRS duration of 114 ms. LAO, left anterior oblique; RAO, right anterior oblique.

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  Figure 4. Left bundle area pacing in a patient with rToF and pulmonary valve prosthesis. (A) Right ventriculogram through the C315H sheath with augmented primary curve, in RAO projection at 20°, revealing the desired location for lead tunnelling, 2 cm distal to the expected His bundle location at the tricuspid valve plane. (B) Right ventriculogram in LAO projection at 20° showing the lead tip tunnelled through the septum, marked by the contrast edge. (C) Baseline ECG showing sinus rhythm (arrows indicate P waves), with first degree AV block and right bundle branch block, QRS duration 175 ms. (D) Post-procedural ECG during left bundle pacing with QRS duration of 148 ms. LAO, left anterior oblique; RAO, right anterior oblique.

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  Figure 5. Pacing parameters at implantation, with 24 h post-procedure and at 2-month follow-up.