Left bundle branch pacing utilizing three dimensional mapping

Permanent His bundle pacing is feasible and effective in patients with atrioventricular block or left bundle branch block. However, pacing thresholds to capture the distal His bundle is often higher. Recently left bundle branch area pacing (LBBP) has been shown to be feasible by advancing the lead transvenously, deep into the interventricular septum to reach the left ventricular endocardial surface. In this article we describe the utility of three dimensional (3D) mapping to achieve LBBP.

Ensite Precision (Abbott) mapping system was used to perform LBBP. A decapolar catheter was used to create 3D map of right atrium and right ventricle (RV). Regions of interest (His bundle, potential LBBP sites of interest in RV) were tagged in the 3D map. The LBBP lead was implanted utilizing the 3D map. The lead depth in the septum was assessed in the 3D map.

LBBP was performed in three patients: chronic LBBB and intermittent 2:1 atrioventricular block; atrioventricular (AV) node ablation and conduction system pacing; and bifascicular block and intermittent AV block in a patient with severe left ventricular hypertrophy. LBBP was successful in all three patients. The lead depth in the interventricular septum was 12, 11, and 21 mm, respectively as assessed by 3D mapping.

Three-dimensional mapping was helpful in achieving LBBP in patients with LBBB, severe left ventricular hypertrophy or during AV node ablation. 3D mapping also facilitated easy assessment of lead depth during and after lead fixation. 3D mapping techniques may be a valuable tool to reduce the learning curve of implanters with minimal experience in LBBP.