Almost zero-fluoroscopy LBBP-procedure using a 3D-mapping system

Abstract Introduction Cardiac device therapy has recently been extended by the option of Conduction System Pacing, CSP (HIS Bundle HBP; Left Branch Area LBBAP). Similar to cardiac resynchronization (CRT), complex procedures can result in long fluoroscopy-duration and considerable radiation exposure for patient implanting team. According principle ALARA (As Low As Reasonably Achievable), measures should be taken reduce radiation, wherever possible. We report almost fluoroscopy-free implantation a LBBAP-system using 3D electroanatomical mapping system (EAMS). The was indicated pace & ablate concept due recurrent, highly symptomatic, persistent atrial fibrillation (AF), history mitral valve repair severely dilated left atrium. ESC guidelines suggest choosing RV-lead (indication IIa), alternatively either CRT or HBP (both IIb). LBBAP as new physiological pacing chosen this because it usually provides excellent stimulation thresholds lead – contrast is distant from Koch's triangle, so that AV-nodal-ablation performed safely. Methods Surgery under deep sedation. After accessing cephalic vein, quick map relevant structures acquired (right atrium; coronary sinus; HIS; interventricular septum, IVS). Then preformed sheath stylet-driven pacemaker-lead were advanced. lead-tip visualized within EAMS maneuvered without fluoroscopy. approaching proximal IVS, site confirmed unipolar advanced into IVS close monitoring impedance signals. Final position sheath-angiography [Fig. 1]. Results During fixation, LBBAP-typical ECG-changes (progression rSR morphology, fixation beats) could observed. A bundle branch potential (poLBB) documented. ventricular activation time (LVAT) marker rapid LV-excitation shortened 108 ms 68 ms. Thresholds non-selective selective LBBP 3 V @ 1 0.7 0.4 ms, with sensing 8.7 mV, 643 ohms paced QRS-width 112 2]. An added (history intermittent sinus rhythm) dual-chamber pacemaker connected. Fluoroscopy required placement well angiography length-optimization. Total fluoroscopy 1.13 minutes dose 45.04 μGy m2, procedure 64 minutes. AVN total ablation following day complications. Conclusions simple, facilitates understanding important anatomical helps necessary minimum. In individual cases, requiring zero-fluoroscopy are Funding Acknowledgement Type funding sources: None.