Left bundle branch area. A new site for physiological pacing: a pilot study
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ORIGINAL ARTICLE
Left bundle branch area. A new site for physiological pacing: a pilot study Asit Das1 · Sk Sahidul Islam1 · Sushant Kumar Pathak1 · Ishita Majumdar1 · Shah Alam Sharwar1 · Ranita Saha1 · Suman Chatterjee2 Received: 10 January 2020 / Accepted: 15 May 2020 © Springer Japan KK, part of Springer Nature 2020
Abstract Chronic RV pacing may lead to pacing induced cardiomyopathy in some patients and results in a higher risk of development of LV systolic dysfunction, heart failure, mitral regurgitation and atrial fibrillation. His bundle pacing emerged as the most physiologic form of ventricular pacing. However, wide adoption of this technique in routine clinical practice is limited by higher capture thresholds at implant sometimes, lower R wave amplitudes, atrial over sensing and increased risk for late rise in pacing thresholds (resulting in the need for lead revisions). Some recent studies have focused on left bundle branch area pacing as a solution to these problems. In our study, we have compared left bundle branch area pacing (in 22 patients) with conventional right ventricular apical pacing (in 28 patients) who presented to us with conventional indications for pacemaker implantations in term of procedure and fluoroscopy time and short-term lead performance and left ventricular function. The results of our study showed that left bundle branch area pacing is associated with shortened QRS duration (22.36 ± 9.36 ms) and better LV function (higher left ventricular ejection fraction 64.00 ± 3.03 vs. 59.73 ± 6.73 with a p value of 0.013 and lower left ventricular diastolic internal diameter 4.58 ± 0.32 vs. 5.23 ± 0.40 cm with a p value of 20% according to some authors) and resulting in an LVEF 50 ms) during unipolar pacing from the anode than the unipolar pacing from the cathode is suggestive of LBB engagement. Atrial lead was positioned in right atrial appendage in all the patients using conventional J-stylet. After positioning, the leads were checked for parameters (R wave sensitivity, pacing threshold and lead impedance). Stability of the leads was checked with deep breath and mild cough maneuver. Once satisfied with the lead parameters, the guiding sheath was removed in LBB area pacing group. Then the leads were connected to the pulse generator and positioned in the preformed pocket. Wound was closed after achieving proper
Fig. 2 Electrocardiographic characteristics during LBBAP lead implantation: Surface ECG and intra-cardiac electrograms from the HB (RVAp) and LBBAP lead (RVAd) area shown at paper speed of 150 mm/s. 1st complex in left panel shows sinus rhythm ECG with
LBBB. 2nd complex in left panel shows paced complex before penetrating the interventricular septum. Right panel shows unipolar paced complex at the LBB area. Middle panel depicts schematic representation pacing site (star)
Fig. 1 Fluoroscopic RAO 30 degree projection showing relative position of the pacing lead in the left bundle branch area AVN AV node, HB his bundle, HBC his bundle catheter, LBB left bundle branch, PL perman
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