No pain, no gain: intraprocedural myocardial injury current and conduction system pacing lead performance

Excerpt

His bundle pacing (HBP) and left bundle branch area pacing (LBBAP) have emerged as two approaches to pace the conduction system [1, 2], with mounting evidence that conduction system pacing (CSP) avoids the deleterious effects of right ventricular myocardial pacing [3]. Additionally, CSP can leverage patients’ dormant bundles and fascicles for cardiac resynchronization, with potential advantages over traditional biventricular pacing [4]. However, implanting CSP leads with existing tools and techniques can be challenging and is not always feasible even for experienced CSP implanters. Additionally, HBP leads have an infamous reputation for higher capture thresholds at time of implant that may rise over time, necessitating lead revision [5]. Although LBBAP leads typically provide low and stable capture thresholds, confirmation of CSP with these leads can be challenging and septal myocardial pacing may masquerade as “successful” CSP. Considering (1) the large and growing volume of device implants worldwide; (2) the potential of CSP to prevent iatrogenesis and correct cardiomyopathy attributable to electrical dyssynchrony; and (3) current limitations with CSP technology and implantation technique, CSP research and development should be a priority for the electrophysiology community. …