Transthoracic Echocardiography-Assisted, Low-Fluoroscopy Left Bundle Branch Area Pacing: A Comparison of Implantation Approaches and Lead Types

Background: Transthoracic echocardiography (TTE)-assisted left bundle branch area pacing (LBBAP) is a potential supplementary to fluoroscopy-guided implantation and may reduce radiation. Objectives: To evaluate the feasibility and long-term stability of TTE-assisted, low-fluoroscopy LBBAP across different workflows and lead types. Methods: This retrospective study enrolled 45 consecutive patients between November 2021 and June 2022, analyzing 42 successful cases. Patients were stratified by workflow approach (non-scrubbed, n = 24; scrubbed aseptic, n = 18) and lead type (lumen-less leads [LLLs], n = 20; stylet-driven leads [SDLs], n = 22). Procedural and pacing parameters were assessed through a 4-year follow-up. Results: In select patients with adequate acoustic windows, multi-stage TTE-assisted LBBAP remained feasible despite a 54.8% overweight/obesity rate. The scrubbed aseptic workflow showed significantly shorter procedural and fluoroscopy times (p < 0.01), though confounded by the learning curve. Beyond 6 months, pacing parameters remained stable and comparable between workflows through 4 years. Regarding lead types, procedural durations were similar. However, the SDL group exhibited significantly higher pacing thresholds at implant and 6 months (p < 0.05) and maintained a higher numerical trend through Year 4, though both lead types demonstrated stable chronic sensing and impedance profiles. No late dislodgements, device-related infections, or late complications occurred across available patient-years. Conclusions: TTE-assisted LBBAP is a clinically feasible approach that can supplement conventional implantation in selected patients with favorable acoustic windows. While achieving excellent 4-year functional durability, procedural improvements reflect the combined effect of workflow refinement and operator proficiency.