Conduction system pacing implantation procedure using fixed AP fluoroscopy projection

Conduction system pacing implantation procedure using fixed AP fluoroscopy projection | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 30 July 2025 V1 Latest version Share on Conduction system pacing implantation procedure using fixed AP fluoroscopy projection Authors : K. Saravanan , Mohd Khairi Othman 0009-0005-4588-3681 [email protected] , Dr. Kantha Rao Narasamuloo , Kenneth Khoo Kay Leong 0009-0008-5812-0925 , Lee Chun Lin , and Aliah Baharin Authors Info & Affiliations https://doi.org/10.22541/au.175384808.81167411/v1 207 views 136 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Conduction system pacing (CSP) is rapidly gaining attention in cardiac pacing to reduce the risk of pacing induced cardiomyopathy and it is more physiological. Multiple technique has been published for a success left bundle branch area capture and it is commonly performed in cardiac electrophysiology laboratory. However, implantation in a fixed AP fluoroscopy projection is not explored. Herein, we report a case series of successful CSP implantation using fixed AP fluoroscopy projection. Conduction system pacing implantation procedure using fixed AP fluoroscopy projection Short title : Conduction system pacing implantation using fixed AP fluoroscopy projection Saravanan Krishinan MD 1,2 ; Mohd Khairi Othman MD 1,2 ; Kantha Rao Narasamuloo MD 2 ; Kenneth Khoo Kay Leong MD 2 ; Aliah Baharin MD 2 ; Lee Chun Lin MD 2 School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia Cardiology Department, Hospital Sultanah Bahiyah, Alor Setar, Malaysia Corresponding author Mohd Khairi Othman School of Medical Sciences, Department of Internal Medicine Universiti Sains Malaysia Kubang Kerian 16150 Malaysia [email protected] Data avaibility statement: The data that support the findings of this study are available from the corresponding author upon reasonable request. Conflict of interest: All authors no declaration of interest. Acknowledgments: None Funding : This research did not received any specific grant from funding agencies in public, commercial or no-for-profit sectors. Ethic approval and patient consent: Written informed consent was obtained from the patient prior the manuscript preparation. Conduction system pacing (CSP) is rapidly gaining attention in cardiac pacing to reduce the risk of pacing induced cardiomyopathy and it is more physiological. Multiple technique has been published for a success left bundle branch area capture and it is commonly performed in cardiac electrophysiology laboratory. However, implantation in a fixed AP fluoroscopy projection is not explored. Herein, we report a case series of successful CSP implantation using fixed AP fluoroscopy projection. Keywords: Conduction system pacing; complete heart block; high-degree AV block; limited fluoroscopy; right ventricular pacing; pacemaker implantation technique Introduction Right ventricular pacing in the long term is associated with pacing-induced cardiomyopathy and increased rate of heart failure hospitalization. A patient who anticipates frequent right ventricular pacing, defined as >20%, is at a high risk of developing these complications. 1 Conduction physiological pacing (CSP) has been receiving rapid attention for its effectiveness in the current era for treatment of bradyarrythmia. Herein, we demonstrate a case of CSP implantation using a limited single plane AP fluoroscopy view . Procedure description In our center, we conduct approximately 500 invasive electrophysiological procedures per year, including pacemaker implantation, with one fully functioning electrophysiological laboratory and one laboratory with limited single-plane AP fluoroscopy only projection. Considering the high volume of cases, we had to implant conventional pacemaker using this electrophysiology laboratory with limited single-plane AP fluoroscopy projection. Despite our cardiac laboratory being in a suboptimal condition, we decided to attempt CSP implantation procedure using a single-plane AP fluoroscopy projection to prove our hypothesis that this procedure can be performed in a limited setting of fluoroscopy projection. We conducted the procedure under conscious sedation. An incision was made at the left pectoral groove, and blunt dissection was performed until the fascia was visualized. Vein access was obtained using two axillary vein cannulation using the Seldinger technique with contrast venography. Before the initiation of LBBAP pacemaker implantation, the atrial lead was implanted in the right ventricle apical apex as a backup pacing and a marker of the tricuspid annulus. The tricuspid valve annulus was identified by the movement of the lead across the tricuspid valve (Figure 1). Subsequently, a conduction system catheter was introduced using a Terumo guidewire into the right outflow tract. By applying counterclockwise maneuver over the catheter while slowly pull back the catheter from the RVOT to engage the septum. Then, the catheter was adjusted until engaging the septum at the midseptum above the tricuspid annulus using the RA lead movement over the tricuspid valve as a marker. With this position being maintained, an RV pacing lead was screwed coaxially with the catheter for the initial myocardial contact (Figure 2). Subsequently, the position was confirmed by pacing to locate the “W” pattern. After identifying the “W” pattern at lead V1, further deeper screwing was performed. Continuous pacing was performed during the lead screwing procedure and stopped when we could demonstrate the Rsr’ pattern in lead VI with an acceptable V6 R wave peak time (V6RWPT) and V6-V1 interpeak interval suggesting left bundle capture. The procedure was continued with the readjustment of the RA lead into the RA chamber in the usual manner. Case Report Patient #1 A 72-year-old woman with no previous medical illness presented with a complaint of giddiness on the day of admission to the district hospital. Upon arrival at the hospital, she was observed to have a complete heart block with an episode of short-run ventricular tachycardia. Clinical examination showed no significant abnormalities. ECG revealed complete heart block with a QRS duration of 124 ms (Figure 3A). Her blood investigation revealed values within the normal range. She was placed on transcutaneous pacing and transferred to our center for the implantation of a permanent dual-chamber pacemaker. Before the procedure, she underwent coronary angiography, which revealed a normal coronary artery, and transvenous pacer was implanted in the right ventricular apex. The patient underwent an implantation procedure as described earlier. She was discharged the next day with no complications, and left bundle branch block was corrected (Figure 3B). Patient #2 A 68-year-old woman with underlying hyperthyroidism had adult-type anomalous left coronary artery to pulmonary artery and type II diabetes mellitus. Her initial presentation to our center was due to recurrent episodes of transient unresponsiveness for 2 months. Her clinical examination was unremarkable. She was extensively investigated for neurological symptoms; however, all results were normal. ECG revealed a first-degree heart block with a QRS duration of 116 ms (Figure 4A). A 24- hour HOLTER monitoring revealed paroxysmal atrial fibrillation with an intermittent-degree heart block. Echocardiography and cardiac MRI showed no significant abnormalities, except for a dilated left atrium. Subsequently, she underwent an electrophysiological study, in which atrial fibrillation was inducible at antegrade burst pacing at 250 ms. No other arrhythmia was inducible. Therefore, she was diagnosed with paroxysmal atrial fibrillation with sick sinus syndrome. Subsequently, she underwent permanent dual-chamber pacemaker implantation, considering she recurrent syncopal attacks. She also underwent a pacemaker implantation procedure using the technique describe above uneventful. She was discharged the next day after the postimplant check revealed a satisfactory result (Figure 4B). Patient #3 A 63-year-old woman with underlying diabetes mellitus, hypertension, and dyslipidemia was referred to our center for recurrent dizziness and presyncopal attack for a duration of 1 month. She had been admitted a couple of times in the district hospital for the symptom. Clinical examination revealed BP 110/80 and PR 40 bpm. Other clinical findings were unremarkable. ECG revealed a 2:1 AV block (Figure 5A). Blood investigations showed values within the normal range. Transthoracic echocardiography revealed LVEF 60%, with left ventricular hypertrophy, and no other remarkable abnormalities were observed. Coronary angiography revealed normal coronary arteries. Subsequently, the atropine challenge test was performed, which showed no response. Considering that she was symptomatic and failed the atropine challenge test, we performed LBBAP. Post procedure ECG revealed a sinus rhythm with Rsrʹ in V1 with a QRS duration of 104 ms (Figure 5B). She was discharged the next day uneventful. Discussion Conduction system pacing (CSP) has recently become a modality of choice in cardiac pacing to reduce the effect of chronic right ventricular pacing and restore ventricular synchrony. 1 The pacing mechanism in CSP has more physiological ventricular pacing, which alleviates the detrimental effect of chronic RV pacing. 2,3 CSP is a broad term that implies the activation of the conduction system at the level of the His bundle or its major branches or their ramifications, including the distal Purkinje fibers. CSP consists of His bundle pacing, right bundle branch pacing, left bundle branch pacing (LBBP), and left fascicular pacing. 1,2 Each pacing strategy has slightly different criteria and definitions. LBBP captures the predivisional left bundle branch with simultaneous activation of its fascicles. 4,5 It is characterized by the deep position of the lead in the interventricular septum, approximately 1–2 cm from the distal His bundle potential or tricuspid valve summit. 4 It is important to understand the right ventricular anatomy and the conduction system before the procedure. The compact AV node is generally situated on the atrial side posterior to the septal leaflet of the tricuspid valve in the triangle of Koch. 4,6 The triangle is defined by the tricuspid valve annulus on the right side, the tendon of Todaro on the left side, and the coronary sinus ostium as a base. The atrial portion of the His bundle runs from the distal end of the AV node in a superior direction to the membranous septum, which is further divided by the septal leaflet into the atrial and ventricular components. 4,6 It perforates the tricuspid annulus, typically close to the anteroseptal commissure. The distal part of the His bundle at the ventricular component of the membranous septum can be reached if the implantation location moves slightly forward through the commissure between the septal and anterior leaflet of the tricuspid annulus and slightly superior. 1,2 Implantation in this lead will result in nonselective His bundle pacing with a “pseudodelta wave” between pacing and sharp deflection of the R wave. As described by Huang et al., LBBP is performed by deploying the lead inside the proximal interventricular septum 1–2 cm from the distal His bundle toward the RV apex. 5 Implanting a pacing lead approximately 1.0–1.5 cm below the tricuspid annulus through the midseptal area may have the highest chance of success. 7 On fluoroscopy, the RAO view at 30° with the lead pointing toward the 2 o’clock position is generally an optimal starting point for transeptal pacing lead implantation. 8,9 On fluoroscopy, the AP view can reliably reflect the site of the lead tip in the caudocranial and left–right axis; however, it cannot discriminate between the posterior and anterior implantation sites 6 . Several techniques have been described for LBBAP lead implantation, including advancing 1.0–1.5 cm in the apical direction using the His bundle as a landmark, using the tricuspid valve annulus as a landmark under fluoroscopic guidance, the method divides the ventricular shadowed into the nine parts and individualized left anterior oblique techniques using guidewire into the inferior vena cava, right ventricular lead into the right ventricular apex. 7 In these case series, we decided to use AP fluoroscopy projection only to implant the RV lead into LBBAP based on an understanding of the anatomy of the conduction system and our electrophysiology laboratory limited setting. We identified the tricuspid annulus based on the movement of the RV lead and used a catheter designed for the LBBAP procedure. In this patient, we demonstrated the successful implantation of LBBAP using a single-plane AP projection, potentially reducing the fluoroscopy time and radiation dose to the patient and operator with acceptable time of procedure. Conclusions The CSP procedure using the PA fluoroscopy view is feasible using the RV lead movement over the tricuspid annulus with an understanding of the anatomy of the conduction system in the PA view. Acknowledgement None Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References 1. Jastrzebski M, Dandamudi G, Burri H, Ellenbogen KA. Conduction system pacing: overview, definitions, and terminology. Eur Heart J 2023;25:G4-G14. doi:10.1093/eurheartjsupp/suad114 2. Arnold AD, Whinnett ZI, Vijayaraman P. His-Purkinje conduction system pacing: State of the art in 2020. Arrhythm Electrophysiol Rev 2020;9:136. doi:10.15420/AER.2020.14 3. Burri H, Jastrzebski M, Cano Ó, et al. EHRA clinical consensus statement on conduction system pacing implantation: endorsed by the Asia Pacific Heart Rhythm Society (APHRS), Canadian Heart Rhythm Society (CHRS), and Latin American Heart Rhythm Society (LAHRS). Europace 2023;25:1208-1236. doi:10.1093/europace/euad043 4. Cabrera JÁ, Porta-Sánchez A, Tung R, Sánchez-Quintana D. Tracking down the anatomy of the left bundle branch to optimize left bundle branch pacing. JACC Case Rep 2020;2:750-755. doi:10.1016/j.jaccas.2020.04.004 5. Huang W, Chen X, Su L, Wu S, Xia X, Vijayaraman P. A beginner’s guide to permanent left bundle branch pacing. Heart Rhythm 2019;16:1791-1796. doi:10.1016/j.hrthm.2019.06.016 6. Israel CW, Tribunyan S, Yen Ho S, Cabrera JA. Anatomy for right ventricular lead implantation. Herzschrittmacherther Elektrophysiol 2022;33:319-326. doi:10.1007/s00399-022-00872-w 7. Hua W, Gu M, Niu H, Gold MR. Advances of implantation techniques for onduction system pacing. JACC Clin Electrophysiol 2022;8:1587-1598. doi:10.1016/j.jacep.2022.09.022 8. Ponnusamy SS, Vijayaraman P. My preferred approach to left bundle branch pacing: Lumenless leads. Heart Rhythm O2 2023;4:147-153. doi:10.1016/j.hroo.2022.12.012 9. Onodera K, Kumazawa D, Mizuno Y, Nomura T, Satomi K, Yamashita K. Individualized right anterior oblique view for reproducible left bundle branch area pacing procedures for each patient. HeartRhythm Case Rep 2024;10:825-829. doi:10.1016/j.hrcr.2024.08.005 Figure captions Figure 1: AP view showed relationship between tricuspid annulus (TA) and intraventricular septum (IVS) with RA lead in the RV apex. SVC: superior vena cava, RA: right atrium, IVC: inferior vena cava. Figure 2: AP view showed relationship between the RV lead and intraventricular septum. RA lead at the RV apex. SVC: superior vena cava, RA: right atrium, IVC: inferior vena cava. Figure 3A and 3B: 12 lead ECG pre procedure showed complete heart block with left bundle branch block and post procedure showed narrow QRS complex with right bundle branch block. Figure 4A and 4B: 12 lead ECG pre and post procedure showed narrower QRS complex with right bundle branch block. Figure 5A and 5B: 12 lead ECG showed high degree AV block pre procedure and pacing ECG post procedure showed LBBAP. Supplementary Material File (table 1.docx) Download 14.31 KB File (table 2.docx) Download 14.25 KB Information & Authors Information Version history V1 Version 1 30 July 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keyword clinical: implantable devices – physiologic pacing Authors Affiliations K. Saravanan Hospital Sultanah Bahiyah View all articles by this author Mohd Khairi Othman 0009-0005-4588-3681 [email protected] Hospital Sultanah Bahiyah View all articles by this author Dr. Kantha Rao Narasamuloo Hospital Sultanah Bahiyah View all articles by this author Kenneth Khoo Kay Leong 0009-0008-5812-0925 Hospital Sultanah Bahiyah View all articles by this author Lee Chun Lin Hospital Sultanah Bahiyah View all articles by this author Aliah Baharin Hospital Sultanah Bahiyah View all articles by this author Metrics & Citations Metrics Article Usage 207 views 136 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation K. Saravanan, Mohd Khairi Othman, Dr. Kantha Rao Narasamuloo, et al. Conduction system pacing implantation procedure using fixed AP fluoroscopy projection. Authorea . 30 July 2025. 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