Introduction Left bundle branch area pacing (LBBAP) aims to achieve physiological pacing by capturing the conduction system in the area of the left bundle branch. LBBAP has exclusively been performed using lumen‐less pacing leads (LLLs) with fixed helix design. This study explores the feasibility, safety, and pacing characteristics of LBBAP using stylet‐driven leads (SDLs) with an extendable helix design. Methods Patients, in which LBBAP was attempted for bradycardia or heart failure pacing indications, were prospectively enrolled at the Ghent University Hospital. LBBAP was attempted with two different systems: 1/LLL with fixed helix (SelectSecure 3830, Medtronic Inc.) delivered through a preshaped sheath (C315His Medtronic Inc.) and 2/SDL with extendable helix (Solia S60, Biotronik, SE & CO) delivered through a new delivery sheath (Selectra 3D, Biotronik). Results The study enrolled 50 patients (mean age: 70 ± 14 years, 44% females). LBBAP with SDL was successful in 20/23 (87%) patients compared with 24/27 (89%) of patients in the LLL group (p = 0.834). Screw attempts, screw implant depth, procedural, and fluoroscopy times were comparable among both groups. Acute LBBAP thresholds were low and comparable between SDL and LLL (0.5 ± 0.15 V vs. 0.4 ± 0.17 V, p = 0.251). Pacing thresholds remained low at 3 ± 2.1 months of follow up in both groups and no lead revisions were necessary. Postprocedural echocardiography revealed a septal coronary artery fistula in one patient with SDLLBBAP. Conclusion LBBAP using stylet‐driven pacing leads is feasible and yields comparable implant success to LBBAP with LLLs. LBBAP thresholds are low and comparable with both types of leads.

Background: Insertable cardiac monitors (ICM) allow prolonged rhythm monitoring, but the diagnostic performance can be hampered by false positive arrhythmia alerts related to inadequate Rwave sensing. This study assesses the prevalence and predictors of inadequate R-wave sensing (both over-and undersensing) among different ICM types. Methods:Patients implanted with an ICM at Ghent University Hospital between January 2017 and August 2018 were included. ICM tracings recorded at interrogation or transmitted by remote monitoring were reviewed for inadequate R-wave sensing leading to false arrhythmia alerts.Patient and implant characteristics were retrieved from the medical records and implant reports. Results: The study screened 135 patients (age 59 ± 19 years, 44% female) implanted with different ICM types: Reveal LINQ TM and XT (Medtronic): n = 92 (68%), Confirm and Confirm Rx (Abbott): n = 35 (26%), and BioMonitor 2 (Biotronik): n = 8 (6%). ICM tracings were analyzed in 112 patients (83%). False arrhythmia alerts occurred in 22 (20%) patients, most frequently related to undersensing (77%). False diagnosis of bradycardia or pause was documented in 64%, false high ventricular rates in 14%, and false atrial fibrillation alerts in 22%. Occurrence of R-wave changes was not related to patient characteristics or implant R-wave sensing. A trend toward higher number of inadequate R-wave sensing seems to occur with nonparasternal implant sites (P = .074). Conclusions: False arrhythmia alerts due to inadequate R-wave sensing occurred in 20% of ICM patients independent of implant features and patient characteristics. K E Y W O R D S arrhythmia detection, implantable loop recorder, insertable cardiac monitor, oversensing, R-wave, undersensing

IntroductionRecent efforts to increase CRT response by multiSPOT pacing (MSP) from multiple bipols on the same left ventricular lead are still inconclusive.AimThe Left Ventricular (LV) MultiSPOTpacing for CRT (iSPOT) study compared the acute hemodynamic response of MSP pacing by using 3 electrodes on a quadripolar lead compared with conventional biventricular pacing (BiV).MethodsPatients with left bundle branch block (LBBB) underwent an acute hemodynamic study to determine the %change in LV+dP/dtmax from baseline atrial pacing compared to the following configurations: BiV pacing with the LV lead in a one of lateral veins, while pacing from the distal, mid, or proximal electrode and all 3 electrodes together (i.e. MSP). All measurements were repeated 4 times at 5 different atrioventricular delays. We also measured QRS-width and individual Q-LV durations.ResultsProtocol was completed in 24 patients, all with LBBB (QRS width 171±20 ms) and 58% ischemic aetiology. The percentage change in LV+dP/dtmax for MSP pacing was 31.0±3.3% (Mean±SE), which was not significantly superior to any BiV pacing configuration: 28.9±3.2% (LV-distal), 28.3±2.7% (LV-mid), and 29.5±3.0% (LV-prox), respectively. Correlation between LV+dP/dtmax and either QRS-width or Q-LV ratio was poor.ConclusionsIn patients with LBBB MultiSPOT LV pacing demonstrated comparable improvement in contractility to best conventional BiV pacing. Optimization of atrioventricular delay is important for the best performance for both BiV and MultiSPOT pacing configurations.Trial RegistrationClinicalTrials.gov NTC01883141

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.

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