Success rates, challenges and troubleshooting of left bundle branch area pacing as a cardiac resynchronization therapy for treating patients with heart failure

Junmeng Zhang, Yimin Zhang, Yaxun Sun, Mengna Chen, Zefeng Wang, Changsheng Ma, Junmeng Zhang, Yimin Zhang, Yaxun Sun, Mengna Chen, Zefeng Wang, Changsheng Ma

Abstract

Cardiac resynchronization therapy (CRT) is an important treatment of heart failure patients with reduced left ventricular ejection fraction (LVEF) and asynchrony of cardiac electromechanical activity. Left bundle branch area pacing (LBBaP) is a novel physiological pacing modality that appears to be an effective method for CRT. LBBaP has several advantages over the traditional biventricular-CRT (BiV-CRT), including a low and stable pacing capture threshold, a high success rate of implantation, a short learning curve, and high economic feasibility. However, LBBaP is not suitable for all heart failure patients needing a CRT and the success rates of LBBaP in heart failure patients is lower because of myocardial fibrosis, non-specific intraventricular conduction disturbance (IVCD), enlargement of the right atrium or right ventricle, etc. In this literature review, we summarize the success rates, challenges, and troubleshooting of LBBaP in heart failure patients needing a CRT.

Keywords: cardiac resynchronization therapy; heart failure; left bundle branch area pacing; success rates; troubleshooting.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2023 Zhang, Zhang, Sun, Chen, Wang and Ma.

Figures

Figure 1
Figure 1
(A) Conventional CRT using BiV-p based on right ventricular pacing and coronary venous pacing. (B) HBP-the real physiological pacing modality directly activate the specialized conduction system. (C) LBBaP is pacing at more distal and deeper area than HBP, and pacing the left bundle branch region directly. (D) The 12-lead ECG after BiV-p, the paced QRS duration was 134 ± 15 ms (7). (E) The 12-lead ECG after HBP, the paced QRS duration was 103.8 ± 13 ms (8). (F) The 12-lead ECG after LBBaP, the paced QRS duration was 114.1 ± 10.7 ms (8). CRT, Cardiac resynchronization therapy; BiV-p, biventricular-pacing; HBP, His bundle pacing; LBBaP, left bundle branch area pacing; ECG, electrocardiogram.
Figure 2
Figure 2
(A) One pacing lead is placed in the His-bundle region—an anatomical landmark. Another pacing lead is screwed into the LBBa. The position of the LBBaP is about 1–1.5 cm distal to the HBP lead position (i.e., the site of the first pacing lead) in the interventricular septum along the line connecting the HBP position and right ventricular apex from the RAO view. (B) The yellow area represents the HB distal region. The green area represents the LBB region that is regarded as an initial implant site of LBBaP. The region of LBB is ~1–1.5 cm distal to the region of HB in the interventricular septum along the line between the region of HB and the right ventricular apex in the right anterior oblique view. (C) The area surrounded by the white dotted lines represents TA. The yellow area represents the HB distal region that is close to the TA summit. The green area represents the LBB region that is regarded as an initial implant site of LBBaP. From the RAO view, the region of LBB is ~1–1.5 cm distal to the region of HB in the interventricular septum along the line between the region of HB and the right ventricular apex. (D) a. The C315HIS delivery sheath with regular curvature; b. The C315HIS delivery sheath with increased curvature. (E) a. Atrial septal puncture sheath (8.5F, T1, 62 cm) and C315HIS delivery sheath; b. Severed atrial septal puncture sheath (8.5F, T1, 62 cm); c. C315HIS delivery sheath coated part of atrial septal puncture sheath. (F) His bundle and LBB are tagged under three-dimensional mapping, followed by pacing lead positioning into the LBBa. (G) We numbered the 3 × 3 partitions from 1 to 9 in the RAO fluoroscopic image of the ventricle. Most successful initial implant sites were found at the junction of the partition zones “4/5/7/8” with more points located in zones “4 and 5”. RAO, right anterior oblique; LBBa, left bundle branch area; HB, His bundle; LBB, left bundle branch; TA, tricuspid annulus; HBP, His bundle pacing.

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