A Guide to Left Bundle Branch Area Pacing Using Stylet-Driven Pacing Leads

Abstract

Left bundle branch area pacing (LBBAP) has emerged as a novel pacing modality which aims to capture the left bundle branch area and avoids the detrimental effects of right ventricular pacing. Current approaches for LBBAP have been developed using lumen-less pacing leads (LLL). Expanding the tools and leads for LBBAP might contribute to a wider adoption of this technique. Standard stylet-driven pacing leads (SDL) differ from current LLL as they are characterized by a wider lead body diameter, are stylet-supported and often have a non-isodiametric extendable helix design. Although LBBAP can be performed safely with SDL, the implant technique of LBBAP differs compared to LLL. In the current overview we describe in detail how different types of SDL can be used to target a deep septal position and provide a practical guide on how to achieve LBBAP using SDL.

Keywords: conduction system pacing; left bundle branch area pacing; lumen-less pacing lead; stylet-driven extendable screw lead; stylet-driven pacing leads.

Conflict of interest statement

JD reports speaker fees and honoraria from Medtronic and Biotronik. AW reports speaker and consultancy fees from Biotronik and Boston Scientific. J-BL reports non-significant speaker fees and honoraria for proctoring and teaching activities from Medtronic, Boston Scientific, Abbott, and Biotronik. The remaining author declares 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 © 2022 De Pooter, Wauters, Van Heuverswyn and Le polain de Waroux.

Figures

Figure 1

(1.1) LBBAP using the Solia S lead (Biotronik). (1A) The helix is extended using the standard clip-on-tool with 10–15 clockwise rotations. (1B) The green stylet insertion tool is connected to the pin of the pacing lead and the silicon rubber separating the inner and outer coil. (1C) Tension to the lead is applied with 10 additional clockwise rotations on the green stylet insertion tool. (1D) Deep septal position of the Solia-S lead on fluoroscopy. (1.2) LBBAP using the Ingevity pacing lead (Boston Scientific). (2A) The closed end of a regular lead cap is cut. (2B) The lead cap is advanced over the lead pin toward the silicone rubber at the proximal part of the lead. The stylet insertion tool is forced between the lead end cap and the pin of the pacing lead and pushed toward the proximal lead part. (2C) The Ingevity lead is screwed in a deep septal position by applying clockwise rotations on the outer lead body. (2D) Deep septal position of the Ingevity lead on fluoroscopy. The red dotted lines indicate the septal borders. (1.3) LBBAP using the Tendril 2088TC pacing lead (Abbott). (3A) The tendril pacing lead can be screwed toward a deep septal position by continuous rotations with the clip-on tool on the pin of the pacing lead. As the helix grips into the tissue, it will further advance into the septum and pull the lead body toward a deep septal position. Often 20–30 clockwise (CW) rotations are needed. (3B) Deep septal position of a Tendril pacing lead. The red dotted lines indicate the septal borders.