A simple method for Bachmann's bundle pacing with indigenous modification of J-stylet

Abstract

Background: Pacing in the Bachmann's bundle (BB) area (upper atrial septum) appears superior to right atrial appendage or free wall stimulation for the prevention of paroxysmal atrial fibrillation in patients with atrial conduction delay. However, insertion of active fixation lead in the upper atrial septal position is difficult and time consuming with conventional stylet, inhibiting application of this pacing method in routine practice.

Methods: The technique of positioning the atrial lead in BB with hand-made stylet is presented with emphasis on electrocardiographic P-wave pattern and fluoroscopic landmarks.

Results: The results demonstrate an acute implantation and short-term success of BB pacing of 14 patients out of 15 patients without major complications. Pacing parameters at implantation and 3 months postprocedure were noted which were within normal limits.

Conclusion: These favorable initial results indicate that the positioning of active fixation atrial lead in BB with fluoroscopic landmarks is feasible and reproducible with a simple technique.

Keywords: Bachmann's bundle; Hand-made stylet; Pacing.

Fig. 1

Anatomical specimen showing an external view of the heart (A) and the antero-posterior view of the right atrial septum (B) The part of the atrial septum above the limbus fossa ovalis is known as upper (high) septum and the rest is lower septum. SVC = superior vena cava, IVC = inferior vena cava, TV = tricuspid valve, RAA = right atrial appendage, FO = fossa ovalis, CS = coronary sinus, US = upper septum, and LS = lower septum.

Fig. 2

Method of Bachmann's bundle pacing. Note the ventricular lead is positioned into the interventricular septum.

Fig. 3

Right atrial appendage pacing: fluoroscopic left anterior oblique view and 12-lead surface ECG.

Fig. 4

Bachmann's bundle pacing: mechanism of impulse propagation – spread of activation wave-front and appearance of P-wave in 6-lead surface ECG during BB pacing in 50 mm/sec speed. In Bachmann's bundle pacing, the wave of depolarization rapidly crosses to the left atrium through the bundle itself, limbus fossa ovalis, along the proximal coronary sinus musculature, and extension from AV node. Along the Crista terminalis, the impulse gets propagated longitudinally in the right atrium. Thus, the left atrium gets stimulated simultaneously or may be little earlier with the right atrium and results in short and sharp P-wave with minimal or no latency period.

Fig. 5

Bachmann's bundle pacing: fluoroscopic left anterior oblique view and 12-lead surface ECG in another patient.