Successful cardiac resynchronization therapy by left bundle branch area pacing through a chronically occluded left
Xiaoke Liu1,2
1Mayo Clinic Health System, La Crosse, Wisconsin, USA.
Insights
Left bundle branch area pacing (LBBAP) offers a solution for cardiac resynchronization therapy (CRT) in patients with limited venous access. This technique successfully improved heart failure symptoms and ejection fraction in a challenging case.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- Conventional cardiac resynchronization therapy (CRT) requires large venous access (≥9 French sheath).
- Limited venous access due to scarring or stenosis can preclude conventional CRT lead implantation.
- Alternative pacing strategies are needed for patients unsuitable for standard CRT.
Observation:
- An 84-year-old male with ischemic dilated cardiomyopathy and worsening heart failure presented with chronic total closure of the left subclavian vein.
- Venous access was limited to a 7 French sheath, preventing conventional coronary sinus lead placement.
- Left bundle branch area pacing (LBBAP) was successfully employed as an alternative CRT strategy.
Findings:
- LBBAP enabled successful CRT implantation despite limited venous access.
- Post-procedure, paced QRS duration narrowed significantly (198 ms to 130 ms).
- The patient showed improved heart failure symptoms and increased ejection fraction (40% to 45%) one month post-procedure.
Implications:
- LBBAP is a viable alternative for achieving CRT in patients with challenging vascular anatomy.
- This technique can improve procedural success rates and clinical outcomes in select patient populations.
- LBBAP expands therapeutic options for heart failure management when conventional CRT is not feasible.
Background:
Conventional cardiac resynchronization therapy (CRT) involves implantation of a coronary sinus pacing lead through a delivery sheath, which typically requires a large venous access through a safe sheath of 9 French or greater in size. In patients who have very limited access due to scar tissue from previous implants or critical venous stenosis/closure, such large caliber access may not be available.
Methods And Results:
We report a case of CRT procedure in an 84-year-old male with a previous history of ischemic dilated cardiomyopathy (ejection fraction 40%) who was dependent on right ventricular pacing with worsening heart failure symptoms. The patient was incidentally discovered to have chronic total closure (CTO) of the left subclavian vein during the procedure. Although the CTO was crossed by a wire and dilated, the venous access was limited to a 7 French sheath which rendered conventional CRT through coronary sinus lead implant impossible. However, using the left bundle branch area pacing (LBBAP) technique which requires a smaller venous access, we were able to successfully achieve CRT. Postprocedure, the patient's paced QRS duration narrowed from 198 to 130 ms. His heart failure symptoms improved, and ejection fraction increased to 45% one-month after the procedure.
Conclusions:
In patients with vascular access limited to a small caliber sheath not suitable for conventional CRT, LBBAP may help achieve procedural success and improve clinical outcome.
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