Comprehensive approach and real-life patient registry: exploring management and patient outcomes in dealing with septal complications during left bundle branch area pacing
Authors: Ozpak E , Van Heuverswyn F , Timmermans F , De Pooter J 
Published: May 2024

Abstract

Background
Left bundle branch area pacing (LBBAP) aims to capture the left bundle branch (LBB) through a transventricular septal approach. Pacing this left-sided conduction system requires deep septal lead positioning due to the subendocardial course of the LBB at the left-sided septum. Such deep septal lead deployment might cause iatrogenic septal complications and collateral damage to septal vasculature.

Purpose
This study aims to explore both the immediate and medium-term clinical results of septal complications during LBBAP in a large single-center patient cohort, while also entailing the management strategies employed to address these issues.

Methods
The LBBAP implant procedure was conducted using a lumen-less (LLL) or a stylet-driven pacing lead (SDL) and a dedicated delivery sheath. Septal complications encompassed septal perforations into the left ventricular cavity, septal coronary artery or venous fistulas (SCAF/SCVF) and septal hematomas, which were identified using fluoroscopy, echocardiography and electrocardiographic criteria.
Enrollment included adult patients who required permanent pacing for bradycardia or heart failure indications in whom LBBAP was attempted between November 2019 and October 2023.

Results
The study enrolled 508 patients, with a mean age of 71±16 years and 60% male. Successful LBBAP was achieved in 471 (93%) patients.
Septal complications during implant occurred in 24/508 patients (5%), including 19 cases of septal perforation (4%), 4 cases of SCAF (0.8%) and 1 case of SCVF (0.2%). All cases of septal perforation were identified during the implantation procedure and were effectively managed by lead retraction and septal repositioning, eventually resulting in successful LBBAP. With regard to SCAF and SCVF, all but one were detected via septography during implantation and were addressed by lead repositioning. One case of SCAF was detected the day after implant on post-procedural echocardiography and was conservatively managed without lead repositioning.
No ventricular septal defects were observed on echocardiography, either immediately or during follow-up (mean follow-up period of 25±12 months). Septal kinetics remained unaffected on follow-up echocardiography (mean follow-up 23±9 months), and all SCAF cases healed spontaneously. Additionally, no septal hematomas were observed.
Importantly, no late septal perforations occurred during the follow-up period. Furthermore, no cardiac ischemia or thoracic discomfort were reported among any of these patients.

Conclusions
The findings of this study underscore the safety of deep septal lead deployment in LBBAP, and highlight that LBBAP provides near physiologic pacing with a high success rate and a low incidence of septal complications. The majority of these complications are promptly detected during the implant procedure and often remain asymptomatic. Furthermore, they exhibit spontaneous healing without enduring persistent septal harm throughout the follow-up period.