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Comparison of Right-Sided vs. Left-Sided Left Bundle Area Lead Implants

Feasibility and safety of right-sided (RS) lead implants were compared to left-sided (LS) implants for His bundle pacing (HBP) in a study involving 245 patients. RS lead implants were found to be highly successful with comparable outcomes to LS implants. No procedural complications were observed in the RS group, while 2% of patients in the LS group experienced acute lead dislodgement. The study demonstrated that RS approaches for HBP can be effective without the need for procedural modifications.

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Comparison of Right-Sided vs. Left-Sided Left Bundle Area Lead Implants

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  1. RIGHT RIGHT- -SIDED VS. LEFT SIDED VS. LEFT- -SIDED LEFT BUNDLE AREA LEAD IMPLANTS SIDED LEFT BUNDLE AREA LEAD IMPLANTS Karina Demchuk, BS; Michael Orlov, MD, PhD; Ioannis Koulouridis, MD; Vybhav Jetty, MD, MHA; Roop Dutta, MD; Danylo Zorin, MD; Artem Astsaturov, MD; Amy Hicks, RT; John Wylie, MD Steward St. Elizabeth’s Medical Center/Tufts University School of Medicine/Boston University School of Medicine, Boston, USA BACKGROUND RESULTS RESULTS (CONT.) Figure: implantations. Bottom row shows angiograms taken during the procedures. Top row displays X-rays after successful His bundle pacing has been challenging for right-sided (RS) access. Success rate for RS left bundle area pacing (LBAP) lead implants is unknown. Thirty-one patients had RS implants and 214 were LS. Medtronic C315™ sheaths were used in all implants. Procedural and pacing characteristics between the RS and the LS implants were comparable and excellent with high success rates for left bundle area pacing in both groups. • No acute lead dislodgment were seen in the RS group. In the LS group, 5 (2%) patients had an acute lead dislodgement. No other procedural complications were found in either group. • One RS patient had revision surgery due to a micro-dislodgement which caused loss of left bundle capture. Twelve LS patients had revision surgery (5 left bundle lead dislodgements, 4 atrial lead dislodgements, 1 battery depletion, 1 upgrade to an ICD, and 1 pocket hematoma drainage). OBJECTIVE To explore the feasibility and safety of RS implants compared to left-sided (LS) implants and any techniques and to compare pacing parameters acutely and chronically. differences in Patients were followed in the outpatient clinics at routine intervals. There was no difference in chronic pacing characteristics between the RS and LS groups. METHODS Procedural and pacing characteristics and electrophysiology parameters in 245 patients who underwent LBAP at SSEMC were extracted from medical records. Table: Procedural and pacing characteristics in patients with right-sided vs. left- sided direct conduction system pacemaker implantation. Right-sided n = 31 Left-sided n = 214 Anatomic failure 0% 13% 0.5 [0.3] 119 [15] 2% 11% 0.5 [0.3] 114 [12] No modifications were applied during the RS procedures. special procedural or tool Electrophysiological failure Capture threshold, Volts QRS width, msec A and C belong to an RS group patient, while B and D belong to a patient from the LS group. Data on RS implants were compared to LS. • Anatomical implant defined as inability to advance the lead into the septum. • Electrophysiologic defined as QRS > 130 msec and/or left ventricular activation time > 90 msec. Ventricular activation time, msec 75 [18] 78 [11] CONCLUSIONS failure was Procedure time, min Fluoroscopy time, min Revision surgery 70 [29] 8.7 [5.6] 3% 80 [37] 8.0 [5.9] 6% • RS LBAP is highly successful and comparable to the LS access. • Sheath modification is not required for RS approach. • Acute and chronic pacing characteristics between both anatomical approaches are similar. failure was Binary variables described as percentage. Continuous variables are given as median [interquartile range].

  2. • Conduction system pacing • Symptomatic bradycardia • Cardiac resynchronization therapy • Older technique: His bundle pacing (HBP) • Rising thresholds • Newer technique: Left bundle area pacing (LBAP) • Wider target site • Direct pacing capture = narrow paced QRS • Lower procedure and fluoroscopy times • Higher success rate • Consistent lead parameters Image: https://www.mdpi.com/2077-0383/10/4/822

  3. • Typically, HBP and LBAP are preformed via a left-sided (LS) approach • One study1reported a right-sided (RS) approach for HBP • Procedural/tool modifications were applied • Acute lead dislodgements still occurred • Concluded that HBP has been challenging for RS access • One case report2demonstrated the efficacy of RS access with tool modification • Currently, the success rate for RS LBAP lead implants is unknown

  4. 1. To explore the feasibility and safety of RS implants compared to left-sided (LS) implants and any differences in techniques. 2. To compare pacing parameters acutely and chronically.

  5. Implant Procedure 1. Confirm right or left approach for implantation 2. Venous access was obtained through the left or right subclavian veins/tributaries 3. Medtronic 3830 pacing lead delivered using the Medtronic C315™ sheath • NO MODIFICATIONS 4. Sheath manipulated through the tricuspid valve and towards the RV septum 5. Unipolar pacing from both the tip and the ring 6. Contrast injection was used to confirm lead location and depth • Impedance-approach3 Image: https://blog.teleme.co/2019/09/13/pacemaker-insertion-for-the- heart/

  6. • This is a retrospective analysis • LBAP procedures between October 2019 and December 2021 • 245 consecutive patients • Procedural and pacing characteristics and electrophysiology parameters were extracted from medical records • Data on RS implants were compared to LS • Anatomical implant failure was defined as inability to advance the lead into the septum • Electrophysiologic failure was defined as QRS > 130 msec and/or left ventricular activation time > 90 msec

  7. PROCEDURE INFORMATION • 31 patients had RS implants and 214 were LS. • Medtronic C315™ sheaths were used in all implants. • Procedural and pacing characteristics between the RS and the LS implants were comparable and excellent with high success rates for LBAP in both groups • Acute lead dislodgment: • NONE in the RS group • 5 (2%) patients from the LS group • No other procedural complications were found in either group.

  8. Right-sided n = 31 0% 13% 0.5 [0.3] 119 [15] Left-sided n = 214 2% 11% 0.5 [0.3] 114 [12] Anatomic failure Electrophysiological failure Capture threshold, Volts QRS width, msec Ventricular activation time, msec 75 [18] 78 [11] Procedure time, min Fluoroscopy time, min Revision surgery 70 [29] 8.7 [5.6] 3% 80 [37] 8.0 [5.9] 6% Binary variables described as percentage. Continuous variables are given as median [interquartile range].

  9. POST-PROCEDURE INFORMATION • Revision surgery • 1 RS patient • Micro-dislodgement which caused loss of left bundle capture. • 12 LS patients • 5 left bundle lead dislodgements • 4 atrial lead dislodgements • 1 battery depletion • 1 upgrade to an ICD • 1 pocket hematoma drainage • Patients were followed in the outpatient clinics at routine intervals • No difference in chronic pacing characteristics between the RS and LS groups

  10. 1. RS LBAP is highly successful and comparable to the LS access. 2. Sheath modification is not required for RS approach. 3. Acute and chronic pacing characteristics between both anatomical approaches are similar.

  11. 1. Vijayaraman P, Ellenbogen KA. Approach to permanent His bundle pacing in challenging implants. Heart Rhythm 2018;15:1428-1431. 2. Prolič Kalinšek T, Žižek D. Right-sided approach to left bundle branch area pacing combined with atrioventricular node ablation in a patient with persistent left superior vena cava and left bundle branch block: a case report. BMC Cardiovasc Disord 2022;22:467. 3. Orlov MV, Nikolaychuk M, Koulouridis I, et al. Left bundle area pacing: Guiding implant depth by ring measurements. Heart Rhythm 2023;20:55-60.

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