Physiologic lead placement with electroanatomic mapping: A case series

Abstract

Introduction His bundle pacing (HBP) and left bundle branch area pacing (LBBAP) have emerged as attractive alternatives to traditional biventricular pacing to achieve cardiac resynchronization therapy. Early reported results have been inconsistent, particularly amongst patients in whom initial placement with traditional approaches has been unsuccessful or those with complex anatomy or congenital abnormalities. In this report, we describe the use of three‐dimensional electroanatomic mapping (EAM) in five selected cases. Methods Five patients from multiple clinical sites underwent EAM‐guided HBP or LBBAP by highly trained electrophysiologists with significant experience with conduction system pacing. Each patient in this series underwent EAM‐guided conduction system pacing due to complex anatomy and/or prior failed lead implantation. Results EAM‐guided lead implantation was successful in all five cases. Capture thresholds were relatively low and patients continued to have evidence of successful lead implantation with minimum 1‐month follow‐up. The fluoroscopy time varied, likely owing to the variable complexity of the cases. Conclusions The use of EAM, in combination with traditional intracardiac electrograms with or without fluoroscopy, allows more targeted and precise placement of leads for HBP and LBBAP pacing. Further investigation is needed to determine this strategy's long‐term performance and to optimize patient selection.

Electroanatomical mapping–guided left bundle branch area pacing in patients with structural heart disease and advanced conduction abnormalities

“…Likewise, the median fluoroscopy time was 24.0 min in a small series of five patients with complex anatomy who underwent EAM-guided CSP (four HBP and one LBBAP). 11 These findings may likely be attributed to the complexity of the cases and EAM protocol used, which included detailed mapping of the HB, RA, and RV with multielectrode catheters. In contrast, we have refined and implemented a standardized protocol for EAM-guided CSP with no need for initial acquisition of 3D right heart geometry, as previously described.…”

“… 2 Electroanatomical mapping guidance holds great potential to facilitate low-fluoroscopy LBBP lead implantation in these patients, but data on EAM-guided LBBAP are scarce and currently limited to case reports and small case series. 10 , 11 …”

Is it feasible to perform permanent left bundle branch area pacing, guided only by an electroanatomical mapping system? Proposal of a zero-fluoroscopy approach

“…To the best of our knowledge, only very few cases of LBBAP have been reported in the literature so far, that have been performed under the guidance of an electroanatomical mapping system: [2][3][4][5] however, among the reported cases, the operators did not abolish fluoroscopy, using it in several of the procedure steps, with a non-negligible range of radiation time between 88 and 840 seconds [2][3][4] or they avoided it, at the expense of using the additional imaging method of intracardiac echocardiography. 5 Our aim was to test whether it is feasible and safe to carry out a procedure of dual chamber pacemaker implantation, including permanent LBBAP, guided only by an electroanatomical mapping system, in such a way as to reduce to zero the fluoroscopy use for leads placement and fixation.…”

“…To the best of our knowledge, only very few cases of LBBAP have been reported in the literature so far that have been performed under the guidance of an electroanatomical mapping system. 2 , 3 , 4 , 5 However, among the reported cases, the operators did not abolish fluoroscopy, using it in several of the procedure steps, with a non-negligible range of radiation time between 88 and 840 seconds 2 , 3 , 4 ; or they avoided it, at the expense of using the additional imaging method of intracardiac echocardiography. 5 …”