Acute performance of stylet driven leads for left bundle branch area pacing: A comparison with lumenless leads

Abstract

Background: Lumenless leads (LLLs) are widely used for left bundle branch area pacing (LBBAP). Recently, stylet-driven leads (SDLs) have also been used for LBBAP.

Objective: The purpose of this study was to evaluate the acute performance of SDLs during LBBAP in comparison with LLLs.

Methods: Consecutive patients undergoing LBBAP for bradycardia or cardiac resynchronization therapy indications at 2 high-volume, early conduction system pacing adopters, tertiary centers were included from January 2019 to July 2023. Patients received either SDLs or LLLs at the discretion of the implanting physician. Acute performance and follow-up data of both lead types were evaluated.

Results: A total of 925 LBBAP implants were included, 655 using LLLs and 270 using SDLs. Overall, LBBAP acute success was significantly higher with LLLs than SDLs (95.3% vs 85.1%, respectively; P <.001) even after the learning curve (97% vs 86%; P = .013). LLLs were implanted in more mid-basal septal positions in comparison with SDLs, which tended to be implanted in more inferior and mid-apical septal positions. Acute lead-related complications were higher with SDLs than LLLs (15.9% vs 6.1%, respectively; P <.001) with 15 cases of lead damage during implant (4.4% vs 0.5%; P <.001) but decreased with acquired experience and were comparable in the last 100 patients included in each group. Lead implant and fluoroscopy times were shorter for SDLs, with lead dislodgment occurring in 0.9% with LLLs and 1.5% with SDLs (P = .489).

Conclusion: Acute lead performance proved to be different between LLLs and SDLs. A specific learning curve should be considered for SDLs even for implanters with extensive previous experience with LLLs.

Keywords: Conduction system pacing; Left bundle branch area pacing; Lumenless leads; Physiological pacing; Stylet-driven leads.

Graphical abstract

Figure 1

Acute septal hematoma in a patient who underwent left bundle branch area pacing (LBBAP) using a stylet-driven lead (Solia S60). A: Four-chamber view of transthoracic echocardiography (TTE) performed just before the procedure. B: Same TTE view performed just after the procedure shows significant thickening of the interventricular septum in the region of final LBBAP lead placement, suggesting the presence of a septal hematoma. The patient was completely asymptomatic, and the septal thickening resolved spontaneously after 2 weeks.

Figure 2

A: Septal contrast staining and visualization of the septal perforation veins during contrast injection through the sheath after penetration of a stylet-driven lead (SDL) (Solia S60) (fluoroscopic left anterior oblique [LAO] 30° view). B: Same patient during lead penetration in a different position in the LAO view. Significant helix distortion was noted, and multiple attempts to unscrew the lead were unsuccessful. C: The lead was extracted with a lead locking device (LLD, Spectranetics) with complete helix elongation. D: TTE performed after the procedure revealed the presence of a severe tricuspid regurgitation that was not present before the implant. E, F: Other examples of helix distortion after screwing attempts in SDLs. Abbreviations as in Figure 1.

Figure 3

Examples of left bundle branch area pacing lead microdislodgment after implant (24 hours later) before discharge in a patient with stylet-driven lead (SDL) (left) and a patient with lumenless lead (LLL) (right). In both cases, significant paced QRS changes can be observed with loss of the “r” prime wave in lead V1 and QRS duration prolongation. Paper speed = 25 mm/s.