Transesophageal echocardiography-guided left bundle branch area pacing significantly reduced total procedure time (65.5 vs 89.9 min, P<0.001) compared to conventional fluoroscopy guidance.
Cohort (n=405)
No
Does TEE-guided LBBAP improve procedural efficiency and electrical outcomes compared to conventional fluoroscopy-guided LBBAP in patients undergoing pacemaker implantation?
Adjunctive TEE guidance during LBBAP implantation improves procedural efficiency and electrical resynchronization compared to conventional fluoroscopy alone.
Absolute Event Rate: 65.5% vs 89.9%
p-value: p=<0.001
Background Conduction System Pacing (CSP), particularly Left Bundle Branch Area Pacing (LBBAP), has emerged as a physiological alternative to conventional ventricular pacing. However, optimal lead placement remains challenging. In this study, we investigated whether intraprocedural transesophageal echocardiography (TEE) can facilitate LBBAP implantation and improve procedural efficiency, lead positioning, and electrical outcomes compared with the conventional fluoroscopy-guided approach. Methods In this single-center, retrospective, non-randomized cohort study, we evaluated 405 consecutive patients undergoing LBBAP between January 2018 and March 2025. The study compared a conventional fluoroscopy-only approach in the initial 198 patients and a TEE-guided approach in the subsequent 207 patients. Primary endpoints were categorized as measures of procedural efficiency assessed by total procedure time and fluoroscopy time and electrical performance evaluated by post-procedural QRS duration, R-wave peak time in lead V6, and final lead impedance. Results The TEE-guided group demonstrated significantly shorter total procedure and fluoroscopy times (65.5 ± 25.2 vs. 89.9 ± 37.9 min; p 140 ms) (ΔQRS: −54 ± 23 vs. −46 ± 21 ms; p < 0.001). Notably, lead impedance was significantly lower with TEE guidance (523.6 ± 115.6 vs. 611.3 ± 155.9 Ω; p < 0.001), while pacing thresholds and R-wave amplitudes were similar. Complication rates were low and comparable. Conclusions TEE-guided LBBAP implantation is associated with enhanced procedural efficiency and adequate cardiac electrical resynchronization. Incorporation of TEE into CSP implantation protocols warrants further evaluation in randomized trials. Graphical abstract Transesophageal echocardiography versus fluoroscopy-guided left bundle branch pacing for pacemaker implant. Representative fluoroscopic and TEE images illustrate left bundle branch pacing with conventional fluoroscopy-only versus adjunctive TEE guidance. TEE allows direct visualization of the interventricular septum and electrode tip, facilitating accurate lead positioning. Quantitative comparisons demonstrate that TEE-guided implantation was associated with significantly shorter fluoroscopy time, comparable or reduced procedure duration, and improved electrical outcomes, including narrower QRS duration and shorter V6 R-wave peak time. RA = right atrium; RV = right ventricle; LA = left atrium; LV = left ventricle; MV = mitral valve; MS = membranous septum; IVS = interventricular septum; TEE = transesophageal echocardiography; LBBP = left bundle branch pacing; RWPT = R-wave peak time
Odozynski et al. (2026) conducted a cohort in Patients undergoing Left Bundle Branch Area Pacing (LBBAP) (n=405). Transesophageal echocardiography (TEE)-guided approach vs. Conventional fluoroscopy-only approach was evaluated on Total procedure time (minutes) (p=<0.001). Transesophageal echocardiography-guided left bundle branch area pacing significantly reduced total procedure time (65.5 vs 89.9 min, P<0.001) compared to conventional fluoroscopy guidance.