Rare Complications of Left Bundle Branch Area Pacing: A Systematic Review of Case-Based Evidence

Left bundle branch area pacing (LBBAP) is increasingly used as a physiological pacing strategy. However, the need for deep septal lead implantation exposes patients to a distinct set of uncommon complications.

To systematically review case reports and case-based studies describing rare complications related to LBBAP.

This review was conducted according to PRISMA 2020. PubMed, Scopus, and Google Scholar were searched for case reports and small case series describing LBBAP-related complications. Given the heterogeneity of the data, a narrative synthesis was performed.

A total of 67 reports were included. Complications were grouped into five categories: septal injury, vascular injury, valvular/subvalvular damage, mechanical or lead-related complications, and electrophysiological disturbances. Septal injury was the most frequently reported, ranging from intraseptal hematoma to delayed perforation presenting with arrhythmias, thromboembolism, or tamponade. Vascular complications included coronary and venous injury, sometimes mimicking acute coronary syndromes. Valvular and mechanical complications occurred despite normal electrical parameters. Electrophysiological complications included ventricular arrhythmias, pacing-induced cardiomyopathy, and T-wave oversensing. Management varied according to the clinical presentation, from conservative observation to lead revision or interventional treatment.

Rare complications of LBBAP reflect the transseptal nature of the procedure and can be grouped into five clinical phenotypes. Recognition requires integration of symptoms, device data, and imaging. Normal device parameters do not exclude clinically relevant structural complications. A phenotype-based approach may help guide diagnosis and management in clinical practice.