Use of extendable helix leads for conduction system pacing: Differences in lead handling and performance lead design impacts conduction system pacing

Abstract

Introduction: Pacing leads with extendable-retractable helix (EHL) are alternatives to fixed-helix leads (FHL) for conduction system pacing (CSP), but data on handling characteristics are limited. This study evaluated a dual-center experience of lead handling and performance during CSP.Methods and Results: Consecutive patients with His-bundle pacing (HBP) or left bundle branch pacing (LBBP) were evaluated for the primary outcome of lead failure, defined as structural damage to the lead necessitating lead replacement. Differences in pacing characteristics were compared. Among 280 patients (mean age 74 ± 11 years, 44% male, 50% LBBP), 246 (88%) received FHL and 34 (12%) received EHL. Of 299 leads used, lead failure occurred more frequently among patients with EHL than FHL (29% vs. 2%, p < .001), regardless of CSP modality.Majority of damaged leads (89%) in the form of helix deformation were successfully removed, with failure occurring in only two patients, both EHL, leading to helix fracture and retention within the septal myocardium. EHL, compared to FHL, was associated with 25-fold increased odds of lead failure (odds ratio: 25.21, 95% confidence interval: 7.35-86.51), and persisted after adjustment in turn for age, pacing modality and indication. CSP implant success rates did not differ by lead design (FHL 80% vs. EHL 71%, p = .18), with similar pacing thresholds at implant and follow-up. Conclusion:Helix deformation and fracture were more frequent with EHL in CSP despite similar implant success. These findings have significant implications for lead selection during CSP and raises concerns about the long-term extractability of EHL in CSP.

Initial experience with stylet‐driven versus lumenless lead delivery systems for left bundle branch area pacing

“…However, further study of the long‐term performance and safety of extraction of LBBP leads (both lumenless and stylet‐driven) is required. While the presence of a lumen to permit use of a locking stylet may facilitate extraction of stylet‐driven LBBP leads, concerns about helix deformation and fracture when extendable‐retractable stylet‐driven leads are used for LBBP have been raised, which complicate efforts at complete extraction 17,18 …”

EHRA clinical consensus statement on conduction system pacing implantation: endorsed by the Asia Pacific Heart Rhythm Society (APHRS), Canadian Heart Rhythm Society (CHRS), and Latin American Heart Rhythm Society (LAHRS)

“…The fixation mechanism of these leads may be relatively easily damaged when they are repositioned after having been fixated on the fibrous tissue of the His bundle region. 89 …”

“… 87 , 92 , 93 Cases of SDL entanglement have been described, resulting in helix fracture, elongation, or disuse upon attempts to remove or reposition the lead. 87 , 89 , 95 It is advisable to avoid entanglement by not continuing to rotate the lead if significant torque build-up is felt during lead fixation. If entanglement is suspected, counter-clockwise rotation and slight traction on the SDL while maintaining tension on the inner lead coil usually untangle the lead.…”

My preferred approach to left bundle branch pacing: Lumenless leads

“… 22 In another study of 280 patients using both LLLs and SDLs for conduction system pacing, SDLs were associated with 29% lead failure (structural damage to the lead necessitating lead replacement) compared with 2% with LLLs. 23 …”