Screw-in attempts and success rates in left bundle branch area pacing lead implantation

FUNDING ACKNOWLEDGEMENTS: Type of funding sources: None. BACKGROUND: Left bundle branch area pacing (LBBAP) represents a novel cardiac pacing approach that overcomes limitations of conventional right ventricular (septo-) apical pacing. Feasibility and early safety have been shown previously. However, technical limitations (non-dedicated leads, limited availability of suitable implantation sheats) still may preclude successful conduction system pacing (CSP) lead implantation. So-called drilling and entanglement effects can prevent lead implantation at a suitable site and multiple screw-in attempts may be required. However, lead implantation may ultimately still be unsuccessful. PURPOSE: To evaluate the number of total screw-in attempts until abandonment of LBBAP lead implantation during the procedure. METHODS: We prospectively assessed 170 consecutive LBBAP lead implantation attempts at our center from 09/2021 to 11/2022. All implanters had previous experience with His-bundle pacing lead implantation. Successful conduction system pacing was established according to standard criteria (R-wave peak time in V6, V1-V6-interpeak interval, programmed stimulation or visibility of a left bundle potential) and pacing thresholds <2V/0.5ms. The number of screw-in attempts and decision of LBBAP lead implantation abandonment was at the operator’s discretion. RESULTS: Patient baseline characteristics and procedural outcomes are shown in the table (percentages and median values with interquartile range in brackets). Overall CSP lead implantation success rate was 91%. Two patients (1%) experienced complications (one atrial lead dislodgement, one pneumothorax). Median number of screw-in attempts in all interventions was 2 (interquartile range [IQR] 1-4, maximum 12). If implantation was successful, a maximum of four attempts provided already 90% of the overall chance of success (figure). Additional lead implantation attempts rarely provided an additional benefit but prolonged overall implantation duration. CONCLUSION: To balance implantation success rates with procedure duration, the number of screw-in attempts during LBBAP lead implantation may be limited to 4-5 attempts. Bail-out strategies (implantation of a cardiac resynchronization pacemaker or a conventional pacemaker) may be considered if CSP lead implantation is unsuccessful after 4-5 attempts. [Figure: see text] [Figure: see text]