Sheath Withdrawal May Represent a Mechanically Vulnerable Phase for Septal Perforation During Left Bundle Branch Area
Masayuki Ohta1, Yuki Ishidoya1, Ryosuke Ito1
1Department of Cardiology, Hokkaido Cardiovascular Hospital, Sapporo, Japan.
Journal of Cardiovascular Electrophysiology
|April 20, 2026
Summary
Sheath withdrawal during left bundle branch area pacing (LBBAP) can cause interventricular septal perforation. Constrained geometry and sheath orientation during this phase amplify forces on the lead tip, increasing perforation risk.
Area of Science:
- Cardiovascular interventions
- Cardiac electrophysiology
- Biomedical engineering
Background:
- Interventricular septal perforation is a known complication of left bundle branch area pacing (LBBAP).
- The precise mechanisms driving this complication, particularly post-fixation events, remain poorly understood.
- Existing research has primarily focused on lead deployment factors, overlooking mechanical forces during sheath removal.
Purpose of the Study:
- To investigate the mechanical forces transmitted along the lead-sheath system during sheath withdrawal in LBBAP.
- To elucidate the role of geometric constraints and sheath orientation in septal perforation risk.
- To identify specific phases and conditions during sheath withdrawal that may lead to lead destabilization or perforation.
Main Methods:
- A benchtop model simulating LBBAP lead-sheath dynamics was employed.
- Axial force transmission was quantified under constrained (5 cm) and less-constrained (10 cm) atrial space configurations.
- Sheath withdrawal was performed incrementally (1 cm) with varying initial sheath orientations (neutral, clockwise, counterclockwise).
- Peak axial forces were analyzed using two-way ANOVA, correlating with clinical fluoroscopic observations.
Main Results:
- Constrained configurations significantly increased peak axial forces compared to less-constrained ones (p < 0.001).
- Counterclockwise sheath orientation under constrained conditions yielded the highest forces (p < 0.001).
- Peak forces occurred early in sheath withdrawal (3.5-4.5 cm lead tip-to-sheath tip distance), mirroring clinical observations of perforation during this phase.
Conclusions:
- Sheath withdrawal is a mechanically critical phase in LBBAP.
- Atrial geometry and sheath orientation synergistically amplify axial forces, elevating perforation risk.
- Awareness of these factors during early sheath withdrawal may mitigate lead destabilization and septal perforation.
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