Key result
LBBAP linked to delayed interventricular septum perforation and severe mitral regurgitation from chordal rupture.
Why the study?
Delayed interventricular septum perforation with mitral chordal rupture after left bundle branch area pacing has not been previously described in detail.
Case Report (n=1)
This case highlights a severe delayed complication of left bundle branch area pacing involving septal perforation and mitral chordal rupture, necessitating lead extraction and surgical valve repair.
Demonstrates LBBAP feasibility with contrast-confirmed septal position; leaves open long-term safety and efficacy in conduction disease.
A 73-year-old man with trifascicular conduction disease and syncope underwent an uncomplicated left bundle branch area pacing (LBBAP) procedure, achieving excellent acute parameters (threshold [email protected] ms, R-wave sensing 6.3 mV, impedance 288 Ω) and demonstrating conduction-system capture. Contrast injection at final lead position delineated the interventricular septum and demonstrated deep septal position of the lead (Panel A and Supplementary data online, Video S1). Transthoracic echocardiography performed the following day confirmed deep septal lead position, without evidence of complications, in particular no mitral regurgitation (MR) (see Supplementary data online, Video S2). At 6-month follow-up, he developed dyspnoea, loss of capture, and new severe primary MR from P2 flail due to chordal rupture (effective regurgitant orifice area 0.44 cm2, regurgitant volume 73 mL). Transoesophageal echocardiography imaging with colour Doppler (panels B and C and Supplementary data online, Video S3) and 3D reconstruction (Panel D and Supplementary data online, Video S4) revealed septal perforation of the LBBAP lead adjacent to the subvalvular apparatus, suggesting lead-related mechanical trauma as the causal mechanism (Arrow: perforated lead; circle: chordal rupture). Lead extraction, conversion to apical right ventricular pacing with a coronary sinus lead (due to high anticipated pacing burden), and minimally invasive mitral valve repair via heart port approach were successfully performed, resulting in complete clinical resolution.
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Dhont et al. (2025) conducted a case report in Trifascicular conduction disease and syncope (n=1). Left bundle branch area pacing (LBBAP) was evaluated on Delayed interventricular septum perforation with mitral chordal rupture. Left bundle branch area pacing resulted in delayed interventricular septum perforation and severe primary mitral regurgitation due to chordal rupture at 6-month follow-up.
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