Extraction of left bundle branch pacing lead: a safe procedure?

Abstract

A 28-year-old woman, with atrial fibrillation and previous cerebral ischaemic stroke, underwent left bundle branch pacing (LBBP) for left bundle branch (LBB) block and heart failure. LBBP was achieved via a transventricular-septal approach using the SelectSecure pacing lead (3830, 69 cm, Medtronic Inc., Minneapolis, MN, USA). The lead was placed about 2 cm distal to the His region and deep into the interventricular septum (Figure 1A). A passive atrial lead and an active implantable cardioverterdefibrillator (ICD) single-coil lead were also implanted. Few months later, she developed worsening heart failure, with lead-related severe tricuspid regurgitation (TR) in the absence of infection, despite optimal medical therapy (Figure 1B,C). Subsequently, she was referred to our Department for both lead extraction and treatment of refractory heart failure, 10 months later, initial implant. The procedure was performed under general anaesthesia. A stiff guidewire from the right femoral vein to the right internal jugular vein for potential use of occlusion balloon in case of vascular lacerations was placed. The ICD lead was removed first using manual traction and locking stylet. The SelectSecure lead in the deep septal LBB location was removed by gentle manual traction and counterclockwise rotations under transesophageal echocardiography (TE) guidance simultaneously (Figure 1D and Supplementary Material). Finally, mechanical extraction tool (Evolution RL 9F, Cook Medical, Bloomington, USA) was necessary for removing the atrial lead. Post-procedural TE revealed a moderate TR and any evidence of interventricular septal defect (Figure 1E,F). Despite a reduction in tricuspid valve regurgitation, the patient is currently under evaluation for heart transplantation for biventricular heart failure refractory to medical therapy. His-bundle pacing, which utilizes the native cardiac conduction system is a well-accepted physiologic pacing. However, it has some limitations, such as operational difficulty and higher pacing thresholds. Thus, recently the LBBP via a transventricular-septal approach has emerged as an alternative physiologic pacing and for correction of LBB block, with a low, stable pacing capture threshold and relatively narrow QRS duration due to fast left ventricular activation and direct excitation of the diseased LBB. However, due to the distal part of the lead burden inside the septum major concerns regarding the impact of lead extraction remain. For long implant LBBP leads which need to use powered sheaths one of the concerns raised is the lack of lumen for placing a locking stylet for extraction. The presence of more leads including the LBBP lead represents a further peculiarity of our case raising others possible concerns for the removal sequence of the leads.