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. 2024 Nov;10(11):2471-2484.
doi: 10.1016/j.jacep.2024.07.025. Epub 2024 Oct 9.

Transseptal Transition Patterns During Left Bundle Branch Area Lead Implantation

Marek Jastrzębski  1 , Grzegorz Kiełbasa  2 , Paweł Moskal  3 , Agnieszka Bednarek  2 , Marek Rajzer  2 , Haran Burri  4 , Karol Curila  5 , Pugazhendhi Vijayaraman  6
Affiliations

Transseptal Transition Patterns During Left Bundle Branch Area Lead Implantation

Marek Jastrzębski et al. JACC Clin Electrophysiol. 2024 Nov.

Abstract

Background: Continuous deep septal pacing and signal recording during implantation of left bundle branch pacing (LBBP) lead enables to monitor beat-to-beat changes of electrocardiogram (ECG) and myocardial current of injury (COI) as the lead crosses the septum.

Objectives: This study aimed to characterize patterns of continuous QRS, ST-T, and COI change for monitoring of the lead depth and instantaneous determination of the obtained capture type (LBBP vs left ventricular septal pacing [LVSP]).

Methods: The ECG and COI during lead implantation were scrutinized for sudden changes of V6 R-wave peak time, V1 initial and terminal R-wave amplitude, V3-V6 R-wave amplitude, repolarization pattern and S-wave amplitude in I, V5-V6, and COI drop. The sudden and gradual transition patterns were diagnosed depending on the presence or absence of the above beat-to-beat ECG phenomena, respectively.

Results: A total of 212 pacemaker recipients were analyzed; LBBP and LVSP were obtained in 77.4% and 22.6%, respectively. There were 4.7 ± 2.1 and 0.2 ± 0.6 beat-to-beat phenomena in LBBP and LVSP patients, respectively. The sudden transition pattern, recognized in 80.7%, had sensitivity and specificity for LBBP diagnosis of 98.8% and 81.2%, respectively. A sudden drop of COI (29.4 ± 8.5 mV to 12.8 ± 4.9 mV) was observed in 53.9% patients (LBBP was simultaneously obtained in 92.7%).

Conclusions: Capture of left bundle branch during lead penetration is a beat-to-beat phenomenon. Two transseptal transition patterns were identified: 1) sudden, which is typical for obtaining LBBP; and 2) gradual, which is typical for obtaining LVSP. A sudden COI drop, a very observable phenomenon, also identified reaching the left subendocardial area.

Keywords: continuous pacing; current of injury; left bundle branch pacing; left ventricular septal pacing; transseptal patterns.

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Conflict of interest statement

Funding Support and Author Disclosures Dr Jastrzębski has received lecture, consultation, and/or proctoring fees from Medtronic, Biotronik, and Abbott; and has served on an advisory board for Boston Scientific. Dr Kiełbasa has received lecture fees from Medtronic and Biotronik. Dr Moskal has received lecture, consultation, and/or proctoring fees from Medtronic and Biotronik. Dr Burri has received speaker honoraria, advisory board fees, and/or institutional research support from Abbott, Biotronik, Boston Scientific, Medtronic, and Microport. Dr Curila has received consulting fees and honoraria from Medtronic, Biotronik, and Abbott. Dr Vijayaraman has received honoraria, consulting fees, and research and fellowship support from Medtronic; has received consulting fees from Abbott; has received honoraria from Boston Scientific and Biotronik; and has a patent for an HBP delivery tool. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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