Left bundle branch pacing (LBBP) provides synchronized contraction of ventricles and overcomes the limitation of His bundle pacing (HBP). The pacing lead is placed deep inside the septum 1-1.5 cm apical to the distal His bundle region. The criteria for capture of left bundle branch (LBB) have been proposed but it has never been validated. LBB potentials may not be demonstrable in all patients. Premature ventricular complexes (PVC) are often noted while positioning the lead in the interventricular septum. The morphology of the PVCs depends on the depth of the lead in the septum. We describe a novel method for lead placement to capture LBB by monitoring the morphology and duration of PVCs in four patients with different pacing indications. Rapid rotations were stopped immediately on observing a PVC with narrow QRS duration and qR (right bundle branch delay) pattern in lead V1. LBB potential and non-selective to selective LBB capture could be demonstrated after placing the lead. PVC guided lead placement would help in final positioning of the lead, avoid perforation into left ventricle cavity and to confirm conduction system capture.
Cardiac pacing is the only effective therapy for patients with symptomatic brady-arrhythmia. Traditional right ventricular apical pacing causes electrical and mechanical dyssynchrony resulting in left ventricular dysfunction, recurrent heart failure and atrial arrhythmias. Physiological pacing activates the normal cardiac conduction thereby providing synchronized contraction of ventricles. Though His bundle pacing (HBP) acts as an ideal physiological pacing modality, it is technically challenging and associated with troubleshooting issues during follow up. Left bundle branch pacing (LBBP) has been suggested as an effective alternative to overcome the limitations of HBP as it provides low and stable pacing threshold, lead stability and correction of distal conduction system disease. This paper will focus on the implantation technique, troubleshooting, clinical implications and a review of published literature of LBBP