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.