A 77-year-old woman with paced-induced cardiomyopathy and depressed left ventricular ejection fraction was admitted to our hospital for left bundle pacing (LBP) for cardiac resynchronization therapy after loss of capture with his-bundle pacing. She had a dual-chamber pacemaker implanted 7 years before.
A lumenless lead (Select-Secure model 3830 69 cm, Medtronic Inc., Minneapolis, MN, USA) was introduced through a fixed preformed sheath (C315 HIS, Medtronic Inc., Minneapolis, MN, USA) according to the technique described for LBP1 after the signed informed consent. From the right ventricle, in a basal septum area of the interventricular septum, the lead was inserted into the septum with 5–6 clockwise turns. After penetration of the lead, contrast was injected through the sheath, filling the perforator branch vein (Figure 1), and the coronary sinus was visualized by flow up to the coronary sinus ostium (Video 1). The lead was then removed with no complication and repositioned more distal in the apical direction. No coronary sinus vein was filled with contrast at this localization. LBP was implemented with optimal parameters (capture threshold 0.5 V at 0.5 ms; sensed R-wave 20 mV) and paced QRS width of 110 ms (Figure 2).
Figure 1.
Left anterior oblique fluoroscopy projection. Lead (LB) penetrating the interventricular septum (red arrow). The panel shows the perforator branch vein (black arrow) and the coronary sinus contrasted (asterisk) by flow from sheath. HB, His-bundle lead; LB, left bundle pacing lead; RA, right atrial lead; S, sheath; V, right ventricular lead.
Figure 2.
Surface electrocardiogram and endocavitary signal sensed by electrode (lower record). First three complexes: left bundle pacing (rsr′ morphology in V1). Last two complexes: sensed R-wave (from old right ventricular lead). Retrograde left bundle branch potential (red arrows).
His-Purkinje conduction system pacing (His-bundle pacing and LBP) restores left ventricular synchrony and decreases the probability of pacing-induced cardiomyopathy.2
Among the most frequent complications are the displacement of the electrode and the significant increase of the pacing threshold. This is the first report of this inusual finding during deep septal penetration of the lead in the interventricular septum. Cho et al.3 have reported their experience in physiological pacing by lead implantation into the septal perforation branch of the great cardiac vein. This shows the close proximity of the His-Purkinje system and the septal branches of the coronary sinus. We propose the systemic use of contrast through the sheath to avoid underdiagnosis.
In the present case, although there are no established recommendations about the management, the replacement of the lead allowed us LBP with no complications in the follow-up, including pericardial effusion.
Consent: The authors confirm that written consent for submission and publication of this case report including images and associated text has been obtained from the patient in line with COPE guidance.
Conflict of interest: None declared.
Funding: None declared.
References
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