A Novel Three-dimensional Mapping Device to Guide Lead Placement for Left Bundle Branch Area Pacing

Navik 3D (APN Health, Waukesha, WI, USA) is a navigation software program that uses two-dimensional (2D) fluoroscopy images to provide three-dimensional (3D) information. Left bundle branch area (LBBA) pacing (LBBAP) is a novel physiologic pacing technique where the lead is placed in the right ventricular (RV) basal septum to capture the left bundle branch (LBB). Precise lead placement in this region can be challenging using 2D fluoroscopy. We studied the feasibility of using Navik 3D to identify the location, plane, and depth of the lead in the septum to assist with LBBAP procedures. This observational, prospective single-center study included 14 patients undergoing LBBAP. Navik 3D was used to identify the LBBA, RV septum, RV apex, and lead position in three dimensions using two orthogonal 2D views. The 3D images were overlaid on real-time, gated fluoroscopic images for navigation of the lead. Images of the 3D locations and successful or unsuccessful lead locations were projected onto 2D fluoroscopic images, allowing for repositioning if necessary. All attempted patients had successful LBBA lead implants. An LBB potential was recorded in 61.5% of the patients. Selective LBBAP was achieved in 85% of the patients. The mean QRS duration postimplant was 129.8 ± 13.1 ms. The mean left ventricular activation time (stimulus R-wave peak in V6) postimplant was 75 ± 12 ms. No acute complications were recorded. 3D localization of the LBBA using the Navik 3D mapping system was feasible and may assist with more appropriate LBBA lead placement.