Standardized Spark-Pattern Cut-Mode Electrosurgical Bailout Workflow for Difficult Left Bundle Branch Area Pacing Lead Advancement: Procedural and Follow-Up Outcomes From a 15-Patient Case Series

BACKGROUND: Electrosurgical facilitation can aid difficult left bundle branch area pacing lead advancement, but standardized delivery patterns, reassessment logic, and follow-up lead performance remain insufficiently defined. METHODS: We retrospectively analyzed 15 consecutive patients undergoing standardized spark-pattern cut-mode electrosurgical bailout after conventional mechanical left bundle branch area pacing lead advancement failed. The generator was operated in unipolar cut-mode at 20 W; spark-pattern delivery denoted brief sliding contact to the exposed cathode segment followed by immediate mechanical readvancement and ECG/electrogram reassessment. A prestandardization sustain-mode polymorphic ventricular tachycardia/ventricular fibrillation event outside the 15-patient cohort informed the safety workflow. RESULTS: Conventional advancement failed in all included patients. Across 50 target-site advancement attempts, spark-pattern cut-mode assistance was activated at 15 final target sites, requiring 1.5±0.6 cycles per patient. Procedural success of left bundle branch area pacing lead deployment was achieved in 15/15. V1 terminal rightward progression occurred in 14/15, jump in 14/15, and split/discrete components in 12/15. Spark-associated premature ventricular complexes occurred in 15/15 but were isolated and self-limited; no nonsustained ventricular tachycardia, sustained ventricular tachycardia, polymorphic ventricular tachycardia/ventricular fibrillation, defibrillation, or hemodynamic instability occurred during the standardized workflow. Mean follow-up was 400±170 days; no clinically documented lead malfunction, dislodgement, microdislodgement, loss requiring revision, septal perforation, ventricular septal defect, pericardial effusion, or reintervention occurred. CONCLUSIONS: A standardized spark-pattern cut-mode bailout workflow provides a reproducible framework for difficult left bundle branch area pacing lead deployment. Progression markers should be distinguished from procedural success, and follow-up surveillance remains essential. Larger studies with longer follow-up and dedicated lead-integrity testing are required before general adoption.