Left Bundle Branch Area Pacing as a Rescue Strategy After Failed Cardiac Resynchronization Therapy in a Patient With Persistent Left Superior Vena Cava, Absent Coronary Sinus Branches, After Bilateral Maze Procedure: A Case Report

Figures

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  Figure 1. Timeline of the case. Initial failed cardiac resynchronization therapy device implantation was followed by clinical deterioration and subsequent rescue therapy using left bundle branch area pacing, resulting in clinical improvement and partial recovery of left ventricular ejection fraction.

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  Figure 2. Selective coronary sinus venography (contrast injection into the coronary sinus). The fluoroscopic image shows the coronary sinus opacified after contrast injection through a catheter introduced via right-sided venous access. The contrast outlines the main trunk of the coronary sinus without an adequate lateral or posterolateral branch suitable for left ventricular lead implantation.

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  Figure 3. Perioperative X-ray documentation of all implanted leads showing the previously implanted left-sided cardiac resynchronization device leads and the newly implanted right-sided implantable cardiac defibrillator system leads. The image shows the course of the persistent left superior vena cava and the dilated coronary sinus before extraction of the previous cardiac resynchronization therapy pacemaker system, highlighting the anatomical limitation for conventional left ventricle lead placement.

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  Figure 4. Final perioperative X-ray image with confirmed lead positions. The final fluoroscopic image after implantation of the implantable cardioverter defibrillator system with left bundle branch area pacemaker stimulation demonstrates stable positioning of the left bundle branch area pacemaker lead within the interventricular septum, consistent with effective conduction system capture. The implantable defibrillator lead remains optimally placed in the apical septum, and the right atrial lead shows appropriate fixation. This final radiograph confirms correct depth and orientation of the left bundle branch area pacemaker lead, ensuring reliable physiological pacing and anticipated resynchronization.

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  Figure 5. Upright chest X-ray on postoperative day 1. Chest radiograph obtained on postoperative day 1 confirming stable positions of all conduction system pacing-related leads, without evidence of dislodgement. The left bundle branch area pacemaker lead maintains appropriate septal orientation, indicative of sustained conduction system engagement. No pneumothorax or early postoperative complications are present.

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  Figure 6. Postoperative electrocardiogram recording. Postoperative electrocardiogram demonstrating non-selective left bundle branch area pacing, characterized by a paced QRS duration of 120 ms.