Introduction
Since it was first described in 2000, His bundle pacing (HBP) as an
alternative pacing site has gained interest steadily
worldwide1. The introduction of new tools, and the
resultant improvement in implantation success rates only spurs this
growth, with its adoption as a routine procedure in many centers. While
providing a more physiological form of pacing is a strong indicator for
HBP, it does have its limitations; the area to land the lead is often
small and difficult to target, capture thresholds are higher, sensing
issues are not uncommon, and the risk of developing distal
atrioventricular block would necessitate the implantation of a
“backup” right ventricular lead2,3,4,5.
To address some of the issues faced in HBP, Left Bundle Branch pacing
(LBBP) has emerged as an attractive alternative. By screwing deep into
the septum, distal to the His bundle and capturing the left bundle
branch in the process, the pacing parameters are often excellent. The
target area to land the lead is also larger and easier to locate, and
the development of distal atrioventricular (AV) block will no longer be
an issue.
The current approach for LBBP relies heavily on the existing tools
developed primarily for HBP. While these tools may prove adequate for
HBP, its suitability for LBBP has yet to be determined. Issues such as
the reach and support provided by the sheaths, torque transmission when
the lead body is rotated, lead tip behavior (both fixed and retractable
stylet driven leads) during deep septal lead deployment, lead stability
and long-term lead performance remains to be determined.
We describe our method for performing LBBP using an Electrodes
incorporated steerable (EIS) catheter (Abbott Agilis
HisProTM), including maneuvers we adopted to overcome
issues such as reach, torque transmission, and helix retraction in a
stylet driven lead system.