Euad 043

Europace (2023) 25, 1208–1236 EHRA DOCUMENT
https://doi.org/10.1093/europace/euad043
EHRA clinical consensus statement

on conduction system pacing implantation:
endorsed by the Asia Pacific Heart Rhythm
Society (APHRS), Canadian Heart Rhythm
Downloaded from https://academic.oup.com/europace/article/25/4/1208/7121146 by guest on 06 January 2024

Society (CHRS), and Latin American Heart
Rhythm Society (LAHRS)
Haran Burri 1*, Marek Jastrzebski2, Óscar Cano3,4, Karol Čurila5, Jan de Pooter6,
Weijian Huang7, Carsten Israel8, Jacqueline Joza9, Jorge Romero10, Kevin Vernooy11,
Pugazhendhi Vijayaraman12, Zachary Whinnett13, and Francesco Zanon14
1
Cardiac Pacing Unit, Cardiology Department, University Hospital of Geneva, Rue Gabrielle Perret Gentil 4, 1211 Geneva 14, Switzerland; 2First Department of Cardiology and
Electrocardiology and Arterial Hypertension, Jagiellonian University, Kopernika 17, 31-501 Kraków, Poland; 3Hospital Universitario y Politecnico La Fe, Avinguda de Fernando Abril
Martorell 106, 46026 Valencia, Spain; 4Centro de Investigaciones Biomédicas en RED en Enfermedades Cardiovasculares (CIBERCV), Av. Monforte de Lemos, 3-5 Pabellón 11, Planta 0
28029 Madrid, Spain; 5Cardiocenter, Third Faculty of Medicine, Charles University and University Hospital, Kralovske Vinohrady, Ruská 87, 100 00 Prague 10, Czech Republic; 6Heart
Centre, University Hospital Ghent, Corneel Heymanslaan 10, 9000 Gent, Belgium; 7The First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou 325000, China;
8
Bethel-Clinic, Burgsteig 13, 33617, Bielefeld, Germany; 9Department of Medicine, McGill University Health Center, 1001 Decarie Boulevard, H4A 3J1 Montreal (Quebec), Canada;
10
Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA; 11Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University
Medical Center, Universiteitssingel 50, 6229 Maastricht, the Netherlands; 12Geisinger Wyoming Valley Medical Center, 1000 East Mountain Blvd., Wilkes-Barre, PA 18711, USA;
13
National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Dovehouse St, London SW3 6LY, UK; and 14Arrhythmia and Electrophysiology Unit, Santa Maria della
Misericordia General Hospital, Viale Tre Martiri 140, 45100 Rovigo, Italy
Received 3 February 2023; accepted after revision 3 February 2023
Abstract Conduction system pacing (CSP) has emerged as a more physiological alternative to right ventricular pacing and is also being
used in selected cases for cardiac resynchronization therapy. His bundle pacing was first introduced over two decades ago
and its use has risen over the last five years with the advent of tools which have facilitated implantation. Left bundle branch
area pacing is more recent but its adoption is growing fast due to a wider target area and excellent electrical parameters.
Nevertheless, as with any intervention, proper technique is a prerequisite for safe and effective delivery of therapy. This
document aims to standardize the procedure and to provide a framework for physicians who wish to start CSP implantation,
or who wish to improve their technique.
-Keywords
--------------------------------------------------------------------------------------------------------------------------------------------------------------
Conduction system pacing • His bundle pacing • Left bundle branch area pacing • Device implantation
consensus on which technique to use for implantation and confirmation

Introduction of conduction tissue capture.
Implantation of conduction system pacing (CSP) has risen dramatically As with the European Heart Rhythm Association (EHRA) consensus
and is gaining mainstream practice in tertiary centres across Europe. document and practical guide on standard pacemaker (PM) and implan
Data on the efficacy and safety of CSP are growing fast, and His bundle table cardioverter defibrillator (ICD) implantation,3 this document aims
pacing (HBP) has been introduced in the European Society of to provide up-to-date guidance for optimal implantation technique of
Cardiology (ESC) supra-ventricular arrhythmia guidelines in 20191 CSP based upon published evidence and expert consensus, in order
and in the ESC pacing guidelines in 2021.2 A number of review articles to standardize the procedure, improve success rates, avoid complica
on how to implant CSP have been written by early adopters of HBP and tions, and ultimately to improve patient outcome. Programming of
left bundle branch area pacing (LBBAP), but there is currently no CSP is covered elsewhere.4–6
* Corresponding author. Tel: +41 22 373 72 00, E-mail address: haran.burri@hcuge.ch

© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/), which permits
non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com
EHRA clinical consensus statement on conduction system pacing implantation 1209
Statements were based upon strength of evidence and consensus At working output, RBBP paced QRS is always non-selective,
was reached by voting with at least 80% agreement by the contributing broader with a prominent pseudo-delta wave, and has longer V6
authors—who all have years of first-hand experience with CSP R-wave peak time (RWPT) than that during HBP, from which it
implantation. may sometimes transition during threshold testing (see Figure 3).
Confirmed capture of the distal RBB by a septal RV lead is rare.11
Definitions Left bundle branch pacing

CSP implies direct activation of the conduction system of the heart by Left bundle branch pacing (LBBP) is defined as capture of the
the pacing stimulus. This can be accomplished by pacing at the level of pre-divisional LBB with simultaneous activation of all of its fascicles.
His bundle or its major branches or their further ramifications including This part of the conduction axis is demarcated proximally by the
distal Purkinje fibres. branching of the His bundle and distally by the first division of the
Determination of the level of conduction system capture rests on the main LBB.
anatomical position of the pacing lead, paced QRS morphology, and the LBBP is characterized by lead position deep in the interventricu

potential to QRS interval (Figure 1). It is important to realize that these lar septum, ∼1–2 cm from the distal His bundle potential (or the
parameters have limitations. Fluoroscopic evaluation of the anatomical tricuspid valve summit), LBB potential to QRS interval in the range
position may be imprecise, paced QRS morphology may be affected
by myocardial substrate, conduction system potentials are not always vi
sualized, or the potential to QRS interval may be lengthened by reduced
conduction velocity of the diseased His–Purkinje system.
The different entities are defined below, and a synopsis is shown in CSP LBBAP
Figure 2.
His bundle pacing

His bundle pacing is defined as capture of the atrioventricular bundle HBP LBBP
with direct activation of all of its fibres. This part of the conduction DSP
LVSP
axis of the heart is demarcated proximally by the distal atrioventricular
node and distally by the division of the His bundle into the right bundle RBBP LFP
branch (RBB) and left bundle branch (LBB).
HBP is characterized by the pacing lead positioned near the tricuspid
valve summit, either on the atrial or on the ventricular side of the tricuspid
annulus, by the His bundle potential to QRS interval at the pacing site
being ≥ 35 ms and the presence of HBP capture criteria.8 In some pa
tients, the distal His bundle may be paced from deep within the septum.9 Figure 2 Synopsis of different entities of CSP and related forms of
stimulation.CSP = conduction system pacing; DSP = deep septal pacing;
Right bundle branch pacing HBP = His bundle pacing; LBBAP = left bundle branch area pacing;
Right bundle branch pacing (RBBP) may be encountered when the im LBPP = left bundle branch pacing; LFP = left fascicular pacing; LVSP
planting physician intends to target the distal His bundle.10 RBBP is char = left ventricular septal pacing; RBBP = right bundle branch pacing.
acterized by criteria outlined in Table 1.
Paced QRS
morphology
LAFP II/III +
Proximal HBP
Distal HBP LSFP II +/iso

III iso/-
RBBP
LBBP LPFP II /III -
LVSP
LBBAP HBP LBBP LFP
LFP
55 ms 35 ms 25 ms 0 ms Potential - QRS interval
Figure 1 Categories of conduction system pacing. Anatomical position of the pacing lead, potential to QRS interval (if visualized), and paced QRS
morphology in leads II and III are used to determine the level of CSP. RBBP and LVSP are not shown on the right panel. HBP = His bundle pacing; iso =
isoelectric; LAFP = left anterior fascicle pacing; LBBAP = left bundle branch area pacing; LBBP = left bundle branch pacing; LFP = left fascicular pacing;
LPFP = left posterior fascicle pacing; LSFP = left septal fascicle pacing; LVSP = left ventricular septal pacing; RBBP = right bundle branch pacing. Modified
with permission from Filip Plesinger and from Jastrzebski et al.7
1210 H. Burri et al.
of 34–25 ms, normal QRS axis, and fulfilled criteria for conduction Left fascicular pacing
system capture (discussed later). In the MELOS registry reporting Left fascicular pacing (LFP) is defined by the capture of one of the LBB
2533 patients with LBBAP from 14 European centres, LBBP was en fascicles or its distal arborization; this part of the conduction system is
countered in only 9% of the patient cohort.7 demarcated proximally by the ramification of the LBB and distally by the
Purkinje fibres to myocardium junction.
LFP is characterized by short potential to QRS interval (<25 ms), often
Table 1 Criteria for RBBP with an abnormal paced QRS axis (usually superior and different com
pared with the native QRS axis) with the presence of criteria for conduc
(1) Pacing lead in the distal His bundle region tion system capture.7 LFP is usually obtained when the pacing site is slightly
(2) Evidence of conduction system capture (transitions in QRS more distant from the His bundle area (2–4 cm) than during LBBP.
morphology or selective conduction system capture) However, even a pacing site apparently quite close to the His bundle
(3) Paced V6RWPT > potential to V6RWPT (Δ > 10 ms) area can result in LFP due to substantial variability in LBB anatomy (early
branching, fan-like ribbon shape, and possibly with sparse transverse inter
(4) Additional findings which may be present:
connections).12 LFP is characterized by a relatively wide implantation tar

(a) Potential—QRS onset interval < 35 ms get on the mid-septum and minimal pseudo-delta wave during
(b) Double transition in QRS morphology during threshold testing non-selective pacing resulting often in a very narrow QRS. LFP may be fur
(requires different thresholds of the tissues): ther defined as being (i) left anterior fascicular pacing (LAFP) with positive
ns-HBP → ns-RBBP → RVSP → loss of capture QRS in leads II and III, (ii) left mid-septal fascicular pacing (LSFP) with posi
ns-HBP → ns-RBBP → s-RBBP → loss of capture tive/isoelectric QRS polarity in lead II and isoelectric/negative QRS polarity
ns-HBP → s-HBP → s-RBBP → loss of capture
in III, and (iii) left posterior fascicular pacing (LPFP) with negative QRS in II
and III. In the MELOS registry, LFP was the dominant form of LBBAP and
(c) Selective paced QRS morphology ≠ intrinsic QRS morphology
was encountered in 69.5% of participants (17.2% LAFP, 27.5% LSFP, and
(unless baseline LBBB or RBBB) 24.8% LPFP).7 Examples are shown in Figure 4.
d) Paced latency > potential to QRS onset interval (requires
selective capture) Left ventricular septal pacing
e) Δ V6RWPT ≤ 20 ms with loss of conduction system capture Left ventricular septal pacing (LVSP) is defined as capture of the left side
of the interventricular septum without direct activation of the left
I
I
II
II
III III
aVR
aVR
aVL
aVL
aVF
aVF
V1
V1
V2 V2
V3
V3
V4
V5
V4
V6
V5
cs1
V6
ns-HBP ns-RBBP s-RBBP LOC Native latency Paced latency
Figure 3 Proximal RBBP with double QRS transition during threshold test. V6 R-wave peak times (V6RWPT) in milliseconds are indicated by the
numbers and transitions are shown by the arrows at the bottom of the figure. Non-selective His bundle pacing (ns-HBP) transitions to non-selective
right bundle branch pacing (ns-RBBP). Prolongation of V6RWPT by 11 ms (there is also a slight change in overall QRS morphology—see lead V2—
illustrating the importance of recording a 12-lead ECG during threshold testing of CSP). Second transition is from ns-RBBP to selective (s-) RBBP.
Note the change in the QRS axis with loss of myocardial capture. Pseudo-shortening of V6RWPT by 2 ms is related to change of R morphology to
rS morphology in V6. The RBB potential to QRS interval of 30 ms recorded at the pacing lead implantation site is much shorter than latency interval
during s-RBBP with a stimulus to QRS interval of 66 ms (not shown). Likewise, the potential to V6RWPT of 68 ms (not shown) is significantly shorter
than the V6RWPT of 92 ms during s-RBBP. Moreover, s-RBBP QRS morphology is different from native QRS (most readily visible in V1–V3).
I I I I I
II II II II
II
III
III III III III
aVR
aVR aVR aVR aVR
aVL aVL aVL aVL aVL

aVF aVF aVF aVF aVF
V1 V1 V1 V1 V1
V2 V2 V2 V2 V2
V3 V3 V3 V3 V3
V4 V4 V4 V4 V4
V5 V5 V5 V5
V5
V6 V6 V6 V6
V6
LBBP LFP LVSP

Figure 4 ECGs illustrating LBBP, LFP, and LVSP. QRS axis results both from conduction system capture and surrounding myocardial capture.
Note the similarity in morphology between LBBP and left LAFP, which may be distinguished by the potential to QRS interval (if present) and
anatomic lead position. The potential to QRS intervals recorded in the intrinsic rhythm by the pacing lead is also shown for LBBP and LFP.
Sweep speed of 25 mm/s for the paced QRS tracings and 100 mm/s for those in intrinsic rhythm. Abbreviations as for Figure 1. Modified with
permission from Jastrzebski et al.7
conduction system. LVSP is characterized by terminal R-wave in V1, deep subendocardial area. DSP is characterized by paced QRS narrower
septal position of the pacing lead in the basal to mid-septal area, and ab than that during right ventricular septal pacing and without notches
sence of criteria for conduction system capture. During LVSP, the left- in the left lateral leads. DSP is differentiated from LBBAP by the lack
sided conduction system may be engaged retrogradely despite the lack of terminal R-wave in lead V1 and no features of left conduction system
of direct capture. In the MELOS registry, 21.5% of patients had LVSP.7 capture.
This type of pacing often results from the inability to progress with
the pacing lead to the left side of the septum. Nevertheless, it offers
Left bundle branch area pacing faster engagement of the left conduction system than RVSP. DSP
LBBAP is defined as capture of the subendocardial area on the left side of should be differentiated from the occasional LBBAP cases without
the interventricular septum,13 with or without simultaneous conduction terminal R-wave in V1 due to the relatively early activation of the
system capture, and includes LBBP, LFP, and LVSP. This term rests on right ventricle.
the anatomical lead position and QRS characteristics (terminal R-wave
in lead V1—although in some cases, this may be absent). LBBAP is a prac
tical designation intended to reflect the common scenario when differen Selective vs. non-selective capture
tiation between LBBP/LFP/LVSP is impossible, uncertain, or not feasible. The terms selective vs. non-selective CSP refer to the absence or pres
Such situations can result from equal capture thresholds or similar refrac ence of the simultaneous capture of the ventricular myocardium adja
toriness between conduction tissue and myocardium and/or nearly iden cent to the conduction system.14
tical paced QRS morphology between LVSP and LBBP/LFP. Non-selective (ns-) HBP is characterized by depolarization starting
immediately after the pacing stimulus and can be recognized by the
Deep septal pacing presence of a pseudo-delta wave in the surface electrogram and/or lo
Deep septal pacing (DSP) indicates that the pacing lead is positioned cal potential fused with the pacing stimulus in the endocardial electro
deep in the septum but does not reach the left ventricular gram. Selective (s-) HBP is characterized by myocardial depolarization
occurring after some latency period and can be diagnosed when there is can be connected to external monitors to facilitate real-time assessment
an isoelectric interval in the surface ECG in all 12 leads and/or discrete during procedure by the operator.
potential after the pacing stimulus in the endocardial electrogram.5,8,15 The implanting physician should be familiar with basic electrophysi
Latency interval during s-HBP corresponds to the HV interval in endo ology of the conduction system, especially the know-how to interpret
cardial electrogram during intrinsic activation, and QRS width should be endocardial signals for diagnosing nodal or infra-nodal block (Figure 6).
measured from QRS onset. Left ventricular synchrony and function Consideration should be given to placing a temporary back-up pacing
seem to be comparable between s-HBP and ns-HBP,16–18 as is the clin lead in patients with a wide junctional escape rhythm or left bundle
ical outcome.19 However, ns-HBP is deemed safer, due to the presence branch block (LBBB). If ICD lead implantation is planned in these pa
of back-up ventricular capture, and sensing parameters are usually su tients, this should be performed first; if an atrial lead is to be implanted,
perior.17 More detailed ECG analysis of HBP is covered elsewhere.8 it can be temporarily positioned in the RV.25 The back-up pacing lead
With LBBP, there often appears to be an isoelectric interval in all 12 should be connected to an additional PSA or external pacemaker while
leads at 100 mm/s display, even with ns-LBBP. By convention, the QRS the CSP lead is being implanted.
width should be measured from the pacing spike.20 At working output
(2.5 V/0.4 ms), ns-LBBP is almost always present. Transition from

ns-LBBP to s-LBBP is mainly observed shortly after lead fixation, Personnel
when the myocardial threshold is initially elevated due to the current CSP implantation is greatly facilitated by having a member of the team
of injury (COI), with equalization of myocardial and conduction tissue who is able to perform the measurements and manoeuvres required to
thresholds thereafter (and is therefore rarely observed at follow-up). It confirm conduction system capture. Prompt recognition of fixation
can be recognized by QRS widening and in V1 a ‘rounded’ appearance beats, drop in impedance, or sudden decrease of myocardial COI is
of the terminal R-wave and prolongation of the V1RWPT and a deeper also facilitated by having a person dedicated to evaluating electrical
S-wave in leads I/V6 (see Figure 22B). Splitting of the paced endocavitary measurements (as the operator may be focusing on fluoroscopy and
electrogram is also observed (see Figures 5 and 22A). handling of the lead).
General considerations His bundle pacing lead implantation

Training A recorded case of HBP implantation is available as video S1.
Even experienced device implanters encounter a learning curve when
they begin implanting conduction system leads, with flattening of the
fluoroscopy duration after 30–50 cases for HBP7,21 and after 110 cases
Locating the His bundle
for LBBP.7 We therefore recommend that new implanters obtain train The His bundle is made up of multiple fibres, which are predestined to
ing in CSP through proctoring or attending dedicated courses. It is also become the RBB and posterior, septal, and anterior fascicles of the
important that allied professionals are properly trained for assisting LBB.26 The His bundle measures approximately 20 mm in length and is
with the procedure to ensure a successful programme. encapsulated in fibrous tissue that insulates it from atrial and ventricular
myocardia; therefore, mere recording of His bundle potential, even near-
field, does not ensure capture. The His bundle begins from the AV nodal
Cardiac catheter laboratory setup tissue and courses along the membranous septum in the right atrium be
A 12-lead ECG is mandatory to assess paced QRS morphology for de fore penetrating to the left side on the crest of the muscular portion of
termining pacing location and confirming conduction tissue capture. the interventricular septum. With lead placement in a proximal His pos
Displaying real-time electrogram signals recorded from the pacing ition on the atrial aspect of the tricuspid annulus, s-HBP is frequently en
lead is also necessary for visualizing endocardial signals. countered, however sometimes with sensing issues (low R-wave
The ECG and lead electrograms are best displayed using an EP re amplitude, atrial/His oversensing); with more distal placement on the
cording system, with the signal from the lead sent to both the pacing ventricular aspect of the annulus, ns-HBP is more frequent, with superior
system analyser (PSA) and EP system using a Y connector or jump electrical parameters compared to proximal HBP.27–29 It is important to
cables (see Figure 5). realize that a significant length of the proximal His bundle rests on the
It is strongly recommended to display both filtered (30–500 Hz) and right atrial–left ventricular part of the membranous septum, which is
unfiltered (0.5–500 Hz) signals. The latter allows visualization of COI. above the tricuspid valve plane, meaning that non-selective His capture
CSP COI impacts acute and long-term capture thresholds22,23 while (i.e. including ventricular myocardial capture) may be observed on the at
myocardial COI is important for assessing tissue contact and monitor rial aspect of the tricuspid annulus.28 Conversely, selective His capture
ing lead depth to diagnose septal perforation.13,24 may be observed on the ventricular aspect of the tricuspid annulus in
Filtered signals at gain settings used for visualizing conduction tissue cases where the His bundle may be superficial and devoid of surrounding
potentials may be clipped. The myocardial COI is therefore more read myocardial tissue.28
ily monitored on a separate unfiltered channel with an adjusted gain set The His bundle can be readily mapped using the pacing lead in a uni
ting which shows the entire ventricular electrogram, or on a PSA. The polar fashion and dedicated electrophysiology catheters are usually not
sweep speed should be set to 50–100 mm/s in order to better distin necessary. The pacing lead is typically delivered through a delivery
guish conduction system potentials from the ventricular potential. sheath (fixed curve or steerable) with a posterior curve which directs
Pacing impedance is measured either via the pacing unit from the EP re the pacing lead to the septum. Once the sheath and lead are placed
cording system or via the PSA, and capture thresholds are measured at the tricuspid annular region, mapping is performed in a 20–30° right
using the PSA. anterior oblique (RAO) view for a site with a near-field (sharp) His sig
If an EP recording system is not available, endocardial signals recorded nal with absent or small far-field atrial electrogram and a larger ventricu
by the pacing lead may be displayed on a PSA, at a 0.05 mV/mm gain. In lar electrogram (Figure 7).
this instance, a 12-lead ECG will also be necessary to confirm conduction If His bundle electrograms cannot be identified, pace mapping at high
tissue capture but does not have the benefit of continuous recording of output (5 V@1 ms) can be performed as an alternative method to lo
signals for review nor electronic callipers for precise measurement of cate the His bundle, yielding narrow paced QRS complexes. This might
timing intervals such as the RWPT. The 12-lead ECG and the PSA screen be especially useful in patients with AV block and no escape rhythm.31
A
EP recording system
PACING SYSTEM ANALYZER

LEAD

ANODE CATHODE
EP PIN BOX
Figure 5 (A) Connection setup for CSP (modified, with permission, from Medtronic). (B) Screen setup with the 12-lead ECG and intracardiac elec
trogram recorded at 100 mm/s sweep speed during LBBAP implantation, with a filtered 30–500 Hz channel (cyan) and unfiltered 0.5–500 Hz channel
(green). V1 and V6 are coloured in yellow to be distinguished from the other leads to facilitate analysis in real time. Note the COI in the unfiltered
channel, and transition from non-selective to selective LBBP (last two cycles) with changes in ECG and EGM morphology. CSP F = conduction system
pacing, filtered; CSP NF = conduction system pacing, non-filtered.
In patients with persistent atrial fibrillation, high-frequency atrial sig bundle and/or to achieve HBP with minimal fluoroscopy.36–40 It
nals can mimic His electrograms. In these patients, it may be reasonable may be more challenging to locate the His bundle with a right-sided
to begin mapping from the ventricular side of the high membranous implant, due to the curvature of the current guiding catheters being
septum. Additionally in patients with atrial fibrillation, it is critical to better suited for a left-sided approach, but this is nevertheless
avoid a His location with large atrial electrograms (>0.5 mV), closer feasible.
to a potential site of AV junction ablation to prevent rise in His capture With stylet-driven leads, mapping of the His bundle with a re
thresholds if ablation is performed.32,33 While His electrograms can be tracted helix can facilitate movement and reduce the possibility of he
easily located preceding the ventricular escape rhythm in patients with lix entrapment in the chorda tendinea or the fibrous tissue
AV block at the nodal level, His electrograms often follow the atrial surrounding the AV node but requires deploying the helix once the
electrograms with short A–H intervals in patients with infra-nodal position is reached (which may result in an advertent modification
(HV) block. in lead position).
Visualization of the tricuspid annulus and/or the triangle of Koch by
injecting contrast at the atrial or ventricular side of the tricuspid valve
via the delivery sheath has been proposed by some investigators to fa Lead fixation
cilitate locating the His bundle (Figure 8 and video S2).34,35 Lead fixation is a crucial part of the HBP procedure which determines
If the His region cannot be easily reached, the delivery sheath can acute and long-term electrical parameters as well as lead stability. The
be appropriately manually reshaped with the dilator in place (which introduction of a fixed delivery catheter with a secondary posterior
avoids kinking the sheath). In patients with challenging anatomy, com (septal) curve has improved electrical parameters and lead stability
plex congenital heart disease, or pregnancy, 3D electroanatomical compared to placement using a two-dimensional deflectable sheath,
mapping may be helpful to facilitate mapping and locating the His thanks to more favourable orientation for lead fixation.41 Once the
Nodal 2:1 AVB
Infra-nodal AVB III + ventricular escape rhythm

Infra-nodal AVB III + temporary ventricular pacing(*)
Figure 6 Examples of sinus rhythm with nodal (top panel) and infra-nodal block (middle and bottom panels). His potentials are only visible with infra-
nodal block during blocked cycles. Pacing spikes (*) from a temporary lead may mimic His potentials. The two bottom tracings were recorded using a
Merlin programmer (Abbott, Sylmar, CA, USA) with filtered (middle panel) and unfiltered (bottom panel) signals at a 0.05 mV/mm gain setting. A =
atrial; AVB = atrioventricular block; H = His; V = ventricular.
target zone has been identified, the delivery catheter must be continu give a ‘U’ form with two additional rotations of the lead to test for
ously controlled by the operator and gently pushed in close contact changes in capture threshold or reduction of His potential amplitude.43
with the cardiac tissue with a counter-clockwise rotation to stabilize
the position while screwing the lead. Some forward force on the lead
may be exerted as the lead body is rotated (without releasing the
Confirming His bundle capture and testing
lead between turns) to facilitate penetration of the helix into the fi electrical parameters
brous tissue surrounding the His bundle. The number of rotations The integral part of testing of electrical parameters is the assessment of
which are necessary to fixate the lead is variable. Resistance to rotation paced 12-lead ECG and confirmation of His bundle capture which is
and torque build-up rather than number of rotations indicates that the covered in detail elsewhere.8,44,45 Briefly, sudden output-dependent
lead is being properly fixated. However, torque build-up may also result transitions in QRS morphology during threshold testing serves as the
from resistance to lead rotations due to angulations of the delivery key method to determine His bundle capture. Morphological features
catheter and does not always imply tissue penetration. There must may also be useful to distinguish His bundle capture from myocardial
be an evident rebound of the lead when it is finally released. If this is capture (see Figure 10).46
not the case, rotations should be repeated, or the delivery catheter Another method is to compare delays to the R-wave peak in V6,
should be repositioned. At this stage, the presence of His bundle from the His potential in intrinsic rhythm and from the pacing stimulus
COI and/or change of His bundle potential polarity from positive to during HBP. His capture is indicated by a difference of <12 ms, with an
negative (often with some widening of the His bundle potential) should accuracy of 96.7%.47
be assessed.22,42 If COI is absent, lead rotation should be repeated with Paced QRS with HB capture and features of the LBBB-like depolar
the aim to create even a stronger torque in the lead than on the previ ization pattern (notch/slur/plateau in leads I, V4–V6, and stimulus-
ous deployment attempt. Often after such manoeuvre, the COI and V6RWPT > 110 ms) indicate non-physiological LV activation and
negative His bundle potential will appear—indicating that despite ap should not be accepted. If transitions are not observed, testing at
parently good initial deployment, the contact between the pacing shorter pulse widths (0.2–0.3 ms) may serve to enhance differences
lead and His bundle was still inadequate, potentially compromising in threshold amplitudes due to divergence of the strength–duration
the long-term threshold stability (Figure 9). Once the lead is fixated, sta curves of the His bundle and myocardium at shorter pulse widths
bility may be assessed by withdrawing the guiding catheter about 5– (see Figure 11).48 In case of doubt, programmed pacing can be useful
8 cm to expose the lead, which can be gently pulled or pushed to and exploits differences in refractoriness of conduction tissue and
Proximal His Bundle

I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
H
H H H
HBP
A A A A
Distal His Bundle

I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
H H H H
HBP
A A
Figure 7 Mapping the distal His bundle in a patient with infra-nodal block. Top panel: intracardiac electrograms from the HBP lead demonstrate a
larger atrial electrogram (A) and prominent His (H ) potential, where distal His capture could be achieved only at a high output due to HV block (despite
COI of the His potential shown by the arrow). Ventricular pacing is delivered by an additional back-up lead. Bottom panel: at a slightly distal location,
much smaller atrial electrogram is noted with His potential (likely far-field) where distal His capture is achieved at low output (1 V). Fluoroscopic images
of the proximal and distal His positions of the HBP lead are shown along with schematic representation of the site of conduction block. Adapted with
permission from Vijayaraman et al.30
myocardium.49 With transitions from ns-HBP to s-HBP, the endocavi

tary electrogram typically shows separation with an isoelectric interval
and change from an initial negative to a positive deflection15 similar to
what is depicted in Figure 5B with LBBP.
The pacing threshold of HBP should be measured at 0.5 ms and, if ele
vated, also at 1 ms. In addition, in case of bundle branch block, the
threshold for correction should be reported. Thresholds ≤ 1.5 V/
0.5 ms are optimal for HBP, but up to 2.0–2.5 V@0.5 ms may be accept
able in some clinical scenarios (e.g. heart failure, only option for electrical
resynchronization). With ns-HBP, myocardial and His bundle thresholds
should be reported separately. The presence of His bundle COI results
in transient high His bundle capture threshold, which should be re-
evaluated at five-minute intervals. In patients with long HV intervals or
HV block, His capture with 1 : 1 HV conduction at cycle lengths ≤ 400
ms50 should be demonstrated at working output. Conduction block
during incremental pacing manifests itself by loss of ventricular capture
or by QRS prolongation with loss of His bundle capture criteria (e.g. de
velopment of notches or slurs). Such observations indicate that the HBP
site is at or proximal to the lesion in the conduction system and a more
distal site should be tried. HBP may result in atrial capture, which can
result in a 1 : 1 ventricular response in case of preserved atrioventricular
conduction and should also not be confounded with selective capture.
Figure 8 Contrast injection via a delivery sheath in a RAO view to Capture thresholds and pacing impedances should be measured in the
delineate the tricuspid annulus. The atrioventricular node (AVN) and unipolar and bipolar modes, and after having withdrawn the guiding catheter
His bundle are depicted in yellow, and the coronary sinus ostium (CS by a few centimetres to avoid artificially lowering thresholds by improving
os) is depicted by the dotted circle. The patient had prior mitral annu lead contact. If non-selective capture is clinically desired (pacemaker-
loplasty and VVI pacemaker implantation and underwent upgrade due dependent patient, high HBP threshold), longer pulse width might be
to pacing-induced cardiomyopathy. used (1.0–1.5 ms); if selective capture is desired (due to a broad ns-HBP
QRS), shorter pulse width might be used (0.2–0.3 ms)—see Figure 11.
Sensing with HBP requires much more attention than with tradition Localizing the lead insertion site
al RV pacing. Bipolar sensing amplitude should ideally be >2.0 mV (or In contrast to HBP, where the His bundle can be directly targeted using
unipolar > 4 mV). It is also important to carefully check for atrial or activation mapping or pacemapping, the LV septal subendocardial
His bundle oversensing which may be fatal in patients with complete course of the LBB implies that only indirect markers of LBB position
heart block. When sensing is inadequate, either a more distal His bundle can be used during the first steps of LBBAP lead implantation. The ini
site should be attempted or an additional RV back-up lead for sensing tially described technique for LBBAP lead positioning relies upon using
should be implanted. In patients with borderline values, it is necessary distal His bundle potential as an anatomical marker and paced QRS
to repeat sensing tests with the lead connected to the device, as filters morphology.52–58 First, the His bundle recording is localized with the
may differ from the PSA, yielding different values. pacing lead and the fluoroscopic location of the His bundle is tagged
In addition to poor sensing by the HBP lead, a ventricular back-up as a reference in the RAO view at 20–30°. The advantage of locating
lead should be considered in specific situations (e.g. pacemaker depend the His bundle is standardization and more accurate location of the ref
ency, high-grade AVB, infra-nodal block, high pacing threshold, and erence point, evaluation of infra-nodal conduction, and evaluating if
planned AVJ ablation) according to the 2021 ESC pacing guidelines HBP is a feasible alternative to LBBAP. Drawbacks are extra time and
(class IIa, level of evidence C recommendations).2

fluoroscopy necessary to localize the His bundle potential and risk of
RBB damage during His bundle mapping. Accordingly, a common modi
fication of this technique is based on skipping His bundle mapping and
Slitting using the tricuspid valve summit (which approximates the His bundle
Before slitting the His bundle lead delivery catheter, the atrial lead and location) as an anatomical marker. Localization of the tricuspid summit
any other additional leads should be implanted to avoid dislodging the can be done using contrast delivery through the guiding sheath, but this
His lead and to provide additional waiting time before retesting the is rarely necessary. Observing the endocardial ‘A’ and ‘V’ potentials and
lead. It is important to maintain adequate slack within the cardiac cham sheath/lead movement, the superior part of the tricuspid annulus can
bers prior to and during sheath removal, to avoid inadvertent lead dis be determined and then tagged to serve as a marker in the same fashion
lodgment. For slitting the sheath, the operator fixes the lead to the as the His bundle potential.
slitting tool, which is kept firmly in place while the other hand pulls Next, the sheath is advanced ∼15–20 mm towards the RV apex, with
back the catheter. If the lead is twisted upon itself after slitting (taking the lead withdrawn within the sheath or the helix retracted with standard
an α shape, usually observed with the 3830 lead), it should be carefully stylet-driven leads (SDLs) to avoid snagging the screw as the sheath
unravelled with a counter-clockwise rotation. Adequate slack, tested crosses the tricuspid annulus. The electrode spacing of the lead gives an
with deep breathing, should be given,51 and the lead tip should be stable idea of distance (most leads have a spacing of ∼15 mm between the
without any rocking motion. The thresholds should be verified after slit tip of the screw and the proximal part of the ring electrode).
ting, once slack is adjusted. Counter-clockwise torque is then applied so that the sheath can reach
the RV basal to mid-septum, where the LBB is expected to be located
at the opposite site of the septum. At this point, the lead is exposed in con
tact with the right side of the interventricular septum and connected in a
unipolar configuration to the PSA. The next step is to evaluate the paced
Left bundle branch area pacing QRS morphology obtained at this initial position. A good site for lead
Cases of LBBAP implantation using lumenless lead and stylet-driven penetration often shows a ‘W’ pattern with a notch at the nadir of V1
lead (SDL) are shown in videos S3 and S4, respectively. QRS (although this is not mandatory) and discordant QRS in leads II
Inital deployment After bonus rotations
T = 1.9 V @0.4 ms T = 0.8 V @0.4 ms
Figure 9 His bundle COI as a marker guiding successful lead deployment. Despite apparently proper lead fixation with ≥5 lead rotations and ac
ceptable acute threshold (left panel), the lead was not well deployed. After additional rotations, torque build-up was felt and a current of injury
(blue arrow) and negative His potential (red arrow) were visible with a significant improvement of capture threshold (right panel). The lead was initially
not in good contact with the His bundle and potentially unstable, thus increasing the risk of late threshold rise. Unipolar electrogram from pacing lead:
uni_f—filters: 30–500 Hz; uni_uf—filters: 0.5–500 Hz.
ECG confirmation of His bundle capture
Transitions in QRS morphology with æ pacing output Morphological features

NS-HBP Myo
8 NS-HBPcorr+
NS-HBP NS-HBP
7
S-HBP plateau
6
S-HBPcorr+ I
Output (V/0.5ms)
5
S-HBP
and/or
4

Myo V4-6
3 S-HBPcorr–
notch
2 LOC
LOC
1 LOC LOC
0
<100ms RWPT >100ms
A B C D V6
NS-HBP = non-selective His bundle pacing Thresholds
S-HBP = selective His bundle pacing His
Myo = myocardial-only capture Myocardium
corr+/– = with/without correction
Bundle branch
LOC = loss of capture
Figure 10 ECG features to diagnose His bundle capture. Left panel: a number of different transitions in QRS morphology may be observed with
decrementing pacing output, reflecting loss of His capture, myocardial capture, or correction of bundle branch block. The sequence of transition
will depend upon the respective thresholds. (A) Obligatory S-HBP. (B) Transition from NS-HBP to S-HBP. (C ) Transition from NS-HBP to myocardial
capture only. (D) Transition from NS-HBP to S-HBP with and without correction of bundle branch block. Right panel: morphological features combining
the absence of plateaus, notching, and/or slurring in leads I, V1, and V4 to V6 and V6 R-wave peak time (RWPT) < 100 ms indicate NS-HBP and allow to
distinguish this entity from simple myocardial capture. Adapted with permission from Burri et al.8
(predominantly positive or equiphasic) and III (equiphasic or predominant the technique allows to identify a pre-systolic fascicular potential
ly/completely negative). Examples are shown in Figure 12. Sites with con on the LBBAP lead if HBP corrects the conduction disorder.63 The
cordant positive or negative QRS polarity in leads II and III can also result in first lead is later removed from the His bundle region and implanted
successful CSP and correspond to LAFP or LPFP, respectively.7 in the atrium.
A refinement of this method was proposed by dividing the septum In patients with dilated right chambers, the delivery sheath may
into sectors. Liu et al.59 describe a technique using contrast injection be reshaped with the dilator in situ to prevent kinking or inserted
in the RAO 30° view to identify the tricuspid annulus summit and to within a shortened coronary sinus catheter for extra support
target a sector located 15–35 mm and between −10° and 30° from and reach.64 LBBAP lead implantation using electroanatomical
this point where LBB/fascicular potentials are often observed with mapping has been performed64,65 and may be useful in challenging
LBBAP (see Figure 13). anatomies.
The technique resulted in a significantly shorter procedure and
fluoroscopic durations and a higher proportion of patients with visu
alization of fascicular potentials compared to their standard proced Penetrating the interventricular septum
ure. A ‘nine-partition method’ in which the RAO 30° fluoroscopic This is the key part of the LBBAP procedure. Once the targeted site
image of the RV is divided into 3 × 3 sectors has also been de for penetration of the interventricular septum is identified, the deliv
scribed.54,60 All these methods target sites which are further away ery catheter should be positioned perpendicular to the interventri
from the His bundle region than the initially described target of cular septum by a slight counter-clockwise rotation. A 30–40° left
1.5–2 cm from the His bundle potential, suggesting that they corres anterior oblique (LAO) view can confirm orientation of the lead.
pond more to LFP than to LBBP. Placement of the LBBAP lead > In this view, the lead should be oriented 10–40° (usually 20–30°) su
16 mm61 or >19 mm62 from the tricuspid annulus was associated periorly with respect to the horizontal plane (see Figure 14). Due to
with less tricuspid valve regurgitation than in a more proximal the curvature of the septum, a superior entry site may have a more
position. horizontal orientation and an inferior site a more vertical
If an atrial lead is also implanted, a modification of the above tech orientation.
nique (‘dual lead technique’) can be used: one lead can be initially Checking lead orientation in RAO can be useful in case of difficulty
fixed at the His position serving as a reference during the implant with lead progression (due to a posterior course—see Figure 15A) or
ation of the second lead in the LBB area. In patients with LBBB, if no terminal r or R-wave appears in lead V1 and change in
6 Initial Final Initial Final

A B
I I
5
II II
III
Threshold voltage (V)
4 III
HB aVR
aVR
3 RV aVL
aVL
s-HBP
aVF

aVF
2 V1
V1
V2
1 V2
V3
V3
V4
0 V4 V5
0 0.5 1 1.5 V5 V6
Pulse duration (ms)
V6
Figure 11 Pacing chronaxie (dots) for His bundle (HB) is shorter
HBED
than for right ventricular (RV) myocardium. Consequently, zone of se HBED
lective pacing (s-HBP) widens with shortening of the pulse duration.

By the same token, longer pulse duration facilitates simultaneous cap
ture of both His bundle and RV myocardium. Adapted, with permis
Figure 12 Localizing the initial lead deployment site on the septum
sion, from Jastrzebski et al.48
with initial pacemapping of the right septum and final position after
screwing the lead up to the left septal sub-endocardium. In panel
(A), there is the recommended QRS polarity in leads II (slightly posi
V6RWPT, despite apparent progression of the lead (due to an anterior tive) and III (negative) while panel (B) illustrates the alternative,
course—see Figure 15B). more inferior implantation site with negative QRS in both II and III.
The lead should be rapidly rotated with some forward push. The nadir notch in V1 (‘W’ morphology) is observed in both cases.
Lumenless leads pull themselves into the septum with rotations of Notably, initial paced QRS morphologies anticipated the final portion
the body, whereas the larger SDLs may require more push.
of the left-sided conduction tissue that was engaged: in case (A), prox
Assessment of lead behaviour during rotations facilitates proper
imal LBB or LSF; in case (B), LPF.
lead deployment (see Figure 16). The ‘screwdriver effect’ is the de
sired smooth progression of the lead in the septum (see video S5).66
When strong torque build-up is observed after the initial rotations,
‘entanglement’ of the endocardium is usually present with little of the lead (see Figure 14). Change of sheath/lead with additional
chance that the lead will penetrate. If the operator insists on trying support can also be tried. As reported in the MELOS registry,7 pene
to traverse the endocardium, it may be difficult to disentangle the tration of the septum with the currently available tools may some
lead for re-positioning without damaging the screw (see video S6). times remain challenging, especially in heart failure patients,
An undesirable ‘drill effect’ results from limited forward progres probably due to chamber enlargement, unfavourable septal orienta
sion of the lead despite multiple rotations of the lead body (see tion, and fibrosis.
video S7). In this instance, a tunnel is formed without proper secur Lead depth during rotations can be determined in various manners
ing of the lead by the screw in the tissue, which may result in lead (frequently, more than one technique is needed to effectively estimate
dislodgment. A ‘drill’ effect should prompt either change of the pos lead depth):
ition on the septum or increase of the lead push/support before
further rotations. (1) Continuous fluoroscopy in the LAO 30–40° view is useful, but progres
In case of difficulty with penetration of the septum, proper orien sion of the lead is often quite subtle. It is impossible to determine ap
tation of the delivery sheath and the lead should be checked, and the propriate lead depth with this method alone.
lead may be repositioned 1–2 cm in a superior, inferior, or apical dir (2) Unipolar paced QRS morphology. As the lead progresses from the right
ection. Push on the sheath may result in excessive bend of the prox side to the left side of the septum, the QRS becomes narrower and
imal curve, with reduced torque transfer to the lead tip. Pulling back loses notches/slurs, a Qr/qR/rsR’/R appears in V1, and the V6RWPT
the sheath slightly after having anchored the lead with a few turns, progressively shortens (Figure 17). When a terminal R-wave appears
in V1, indicating RV activation delay, screwing of the lead should be
while maintaining counter-clockwise torque to provide good con
interrupted to evaluate the LBBP ECG criteria described in detail be
tact and support, will straighten the proximal curve (ideally to low. Ideally, pacing should be un-interrupted during screwing of the
<90°) and facilitate rotation of the lead and septal penetration. lead, which is readily feasible with SDLs by connecting the crocodile
Contrast injection via the delivery catheter to delineate the clip cathode to the stylet.67 Revolving adapters are being developed
curvature of the septum may optimize perpendicular orientation for use with the 3830 lumenless lead.68,69

Figure 13 Insertion site for left bundle area pacing. In a RAO view at 30° with pacing lead in the left bundle area (LBBA) region, contrast is injected
through a sheath delineating right atrial and ventricular anatomy. Tricuspid valve leaflets are identified by contrast. The summit of the tricuspid annulus
indicates the approximate His bundle (HB) position. The red arrow indicates an imaginary line that connects the tricuspid annulus summit/His bundle
with the RV apex, which can serve as a guide for placing the left bundle area lead. Successful pacing sites can be localized within a sector (indicated in
yellow) located 15–35 mm away from the tricuspid annulus summit and at an angle of −10° to 30°, as described by Liu et al.59
Figure 14 Left panel: LAO view for orienting the lead 10–40° (most often 20–30°) with respect to the horizontal plane for perpendicular septal
penetration. Right panel: example of lead orientation assisted by septography in the LAO view.
(3) Fixation (template) beats. These are premature ventricular depolar rounded R’ in aVR and V1) and have been termed ‘M’ beats.69,72
izations that are evoked by the mechanical trauma as the lead passes Fixation beats which originate from conduction tissue may display
through the interventricular septum and are observed in 59–96% of an LBB/fascicular potential,52 which is useful in the setting of
cases.70–72 Morphology of these beats corresponds very well with LBBP (where pre-systolic potentials are not visualized during con
the actual depth of the lead tip and paced QRS complex from ducted cycles).
that location. Premature beats with terminal r or R-wave in V1 (4) Unipolar pacing impedance. This usually rises initially and then falls as
can serve as a marker that the lead rotations should be interrupted the lead approaches the LV endocardium. Care should be taken
and ECG criteria tested since the lead is approaching or has reached when values approach 500 Ω or impedance drops by 200 Ω. It is im
the left subendocardial area.70,71 An example is shown in Figure 18. portant to note that pacing impedance depends not only on lead/tis
Fixation beats may be identical to selective LBB capture (with a sue conduction but also upon the connections and cables and may

Figure 15 Importance of the RAO view for evaluating issues with lead orientation which may appear adequate in the LAO view (top panels) and after
re-positioning (bottom panels) in two patients. (A) Patient without clear progression of the lead in LAO view, with basal orientation of the lead revealed
by the RAO view. (B) Another patient with apparent lead progression in the LAO view but without terminal R in V1 and no change in V6RWPT, with
antero-apical orientation of the lead revealed by the RAO view.
Entanglement Drill Screwdriver
Desired depth
and stable
Lead damage or Micro-or macro- Partial or overt

entrapment dislodgment perforation
Figure 16 Lead behaviour during penetration of the septum during LBBAP. Both drill and screwdriver effects can result in perforation.
vary from lab to lab. A steep rise in impedance with a standard lead COI gives the operator assurance that another lead rotation might be
indicates retraction of the extendible helix. safely performed in the pursuit of LBB capture or better paced QRS.
(5) Myocardial COI. After an initial rise in amplitude (to about 20–35 mV), Therefore, if there is a clear drop-in COI amplitude (to approximately
the sensed COI decreases as the lead reaches the LV subendocardial 5 mV based upon our experience), care with further screwing of the
area to an average of approximately 10–12 mV (Figure 19).73,74 High lead is advised (see section on complications). The COI may fall over
RV septum Deep septum LV septum LBB capture
aVF
V1
V2

V3
V4
V5
V6
RWPT 124 124 121 121 104 100 100 100 96 96 84 84 84 84 76 68 68 68 (ms)
Figure 17 Pacemapping for lead depth in the septum. Continuous pacing during intra-septal lead deployment enables to monitor continuous change
of paced QRS complex morphology and lead depth in the septum. The right ventricular (RV septum) paced QRS is characterized by notches in lateral
leads, ‘W’ morphology in V1, and time to R-wave peak (RWPT) in V6 > 120 ms. Deep septal paced QRS is narrower and loses notches in lateral leads,
the notch in V1 moves towards the end of QRS, and V6RWPT is usually in the range of 120–95 ms. Pacing close to the left bundle branch area (LV
septum) QRS is characterized by a positive terminal component in lead V1, pseudo-delta in leads V5–V6, and V6RWPT of 95–80 ms. LBB capture paced
QRS is characterized by deeper S-wave in leads I, V5–V6, more prominent R in V1–V3, and V6RWPT usually <80 ms. LBB capture in the current case
was assured both by V6RWPT < 74 ms and transition to selective capture (not shown).
LBB
¨¨ Fixation beats
¨ Fixation beats of QR/rSR’ morphology during intraseptal

lead implantation indicate with high sensitivity (96.5%) and
RV LV specificity (97.4%) that the left bundle branch area was reached.
Figure 18 Fixation (or ‘template’) beats of different morphologies, reflecting depth of lead penetration. Reproduced with permission from
Jastrzebski et al.70
V1
ENDO
filtered
ENDO

unfiltered
Figure 19 Myocardial COI during lead progression. A 15 s strip of the endocardial signals from the lead tip recorded during LBBAP implantation with
continuous pacing at 100 bpm. Immediately after the premature fixation beat, preceded by a Purkinje potential (arrow), there is an obvious drop of the
paced myocardial COI. Both COI drop and Purkinje potential are valuable markers indicating that the subendocardial area of the interventricular sep
tum was reached by the pacing lead tip and that the lead rotations should be immediately stopped. In the present case, the lead rotations were con
tinued and a further decrease in COI was observed (<4 mV and <25% of V wave), indicating imminent perforation. The endocardial signals (ENDO)
from the pacing lead are acquired in unipolar mode and presented as filtered (30–100 Hz) and unfiltered (0.1–500 Hz). Sweep speed 12.5 mm/s.
Reproduced, with permission from Jastrzebski et al.75
10 min and be accompanied by an improvement in capture thresholds direct LBB capture, indirect left conduction system engagement follow
if these were initially elevated.73 COI should be evaluated during uni ing myocardial capture can occur when the pacing lead is the subendo
polar sensing, but a fall in the COI during pacing may also be observed cardial area of the LV septum. Visualization of an LBB or fascicular
(Figure 19).75 The COI may fall/disappear with bipolar sensing config potential does not necessarily mean that conduction system capture
uration, but this has no pathological significance.
will be obtained at low thresholds, and, conversely, conduction system
(6) Visualization of an LBB/fascicular potential. These potentials are not vi
sualized in all patients, but if present, they indicate that the subendo capture at excellent thresholds may be obtained without the presence
cardial area has been reached and that any further rotations (e.g. to of a potential.
lower capture thresholds) should be performed with extreme caution The most useful methods for confirming LBB capture are summar
as this may result in perforation. The presence of a COI of the poten ized below and covered in detail elsewhere.45,78,79
tial indicates that further rotations are contraindicated.23 In the setting
of LBBB, pre-systolic LBB/fascicular potentials are only visualized if (1) Transition in QRS morphology is the gold standard to assess cap
LBBB is intermittent,76 in case of fixation beats originating from con ture. To demonstrate QRS transition, differences in excitability
duction tissue,52 or if a ‘dual lead technique’ is used with corrective (threshold test) and/or refractoriness (programmed stimulation)
HBP (see section 5.1). However, in some cases, a retrograde or de between the conduction system and myocardium can be
layed fascicular potential may be visualized within the ventricular elec exploited.
trogram (see Figure 20). (a) Threshold test. Decremental voltage output pacing is the re
An LBB/fascicular potential was visualized in 26.4% of patients in the commended initial method to confirm capture52 and should
MELOS registry,7 but in as many as 98.3% of cases in series targeting be performed in the unipolar mode to avoid transitions in
QRS morphology due to anodal capture. The pacing ampli
more proximal implantation sites.23
tude is slowly decreased from high value (5–10 V@0.5 ms)
(1) Contrast injection through the delivery catheter to delineate the sep to demonstrate a transition between simultaneous capture
tum can provide rough insight as to the depth of the lead of LBB and septal myocardium (ns-LBBP) to selective cap
(Figure 21).52 Simply advancing the delivery catheter up against the ture of either only LBB (s-LBBP) or only septal myocardium
septum also gives an idea of lead depth. (LVSP)—see Figure 22. If no transition is detected, then, the
(2) Capture with cathodal pacing from the ring electrode indicates that the lead test is non-conclusive because capture thresholds of the
has penetrated the septum to some extent (Figure 21). However, as with LBB and septal myocardium may be nearly equal. This meth
contrast injection, due to variable septal thickness and oblique course of od has higher diagnostic yield when performed immediately
the lead, it provides little information regarding proximity to the LBB after lead deployment, because the myocardial threshold is
area (despite knowing inter-electrode spacing). transiently elevated by acute injury. Only 26.4% of patients
(3) ‘Hinge point’ of the lead is an imprecise marker of lead depth, as it lies with LBB/fascicular capture showed this feature in the
proximal to the ring electrode and will not give indication of how deep MELOS registry,7 but demonstration of s-LBBP has been re
the lead tip is embedded. A rocking motion of the lead tip however ported in up to 75.4% of patients at implantation (and
indicates that there has been little penetration. 30.9% at follow-up), targeting more proximal LBBP sites.63
(b) Physiology-based ECG criteria. With capture of the conduction
system during LBBAP, the delay of the LBB potential to
Confirmation of left conduction system V6RWPT in intrinsic rhythm should equal that of the stimulus
capture and testing of electrical to V6RWPT during pacing (Figure 24). Allowing for variability
in measurement, a difference <10 ms has a sensitivity of
parameters 88.2% and specificity of 95.4% for confirming conduction system
Differentiation between capture types during LBBAP is more challen capture.83 To increase the usefulness of this method for moni
ging than for HBP and of less clear clinical significance. Even without toring loss of LBB capture during follow-up, it is recommended
I
II
III
aVR
aVL
aVF
V1
V2

V3
V4
V5
V6
LBBP
100 mm/s
Figure 20 Left bundle branch pacing lead implantation in a patient with LBBB, with electrograms during an intrinsic-conducted rhythm. A fascicular
potential (arrows) is visualized within the ventricular electrogram during LBBB (first and last cycles) and is pre-systolic when the QRS narrows following
a pause (after an atrial premature beat, not visible here). Modified, with permission, from Kaddour et al.77
A Septography via sheath B Pacing from the RING electrode
RV cavity RV endocardium Deep septum
Figure 21 (A) Contrast injection via delivery sheath to delineate the endocardial surface and depth of penetration of the intra-septal lead. (B) Pacing
from the ring electrode also provides information regarding depth of penetration.
that potential to V6 peak interval value be included in the im V6RWPT is <50 ms, while it is >60 ms in the presence of LBBB.
plantation procedure report. During CSP, the same rules apply. The measurement is performed
(2) V6RWPT is often used as a surrogate of activation delay of the lateral from the pacing stimulus to the peak of the R-wave in V6. Latency re
LV. However, timing of local depolarization is more accurately evalu sulting from conduction tissue activation (approximately 30 ms, dur
ated by maximum dV/dT (which is impractical to use as it requires ing which a pseudo-delta wave is visible due to myocardial capture)
special software). During intrinsic rhythm with a narrow QRS, should be added to the 50 ms V6RWPT to confirm conduction tissue
A nsLBBP to LVSP B nsLBBP to sLBBP

0.5V @ 0.5 ms 0.4V @ 0.5 ms 1V @ 0.5 ms 0.9V @ 0.5 ms
02 02.50 17 17.50
I I
II II
III III
aVR aVR
aVL aVL
aVF aVF
V1
V1
V2
V2
V3

V3
V4
V4
V5
V5
V6
V6
70 ms 86 ms
70 ms 70 ms
EGM
Capture @ 0.4V @ 0.5 ms EGM Capture @ 0.9V @ 0.5 ms
Capture @ 0.5V at 0.5 ms Capture @ 1 V at 0.5 ms
Figure 22 (A) Transition between ns-LBBP and myocardial capture only with LVSP at 0.5 V@0.5 ms. This type of transition is characterized by prolonga
tion of the V6RWPT, terminal R, or r amplitude decrease in V1 and usually by the disappearance of the S-wave in I/V6 during myocardial capture, but without a
significant change in the local ventricular EGM signal. (B) A transition between ns-LBBP and s-LBBP at 1 V@0.5 ms is shown. This type of transition is char
acterized by prolongation of the QRS (measured from the pacing artefact). Usually, there is a change in QRS morphology from QR/qR to rSR in V1 (with
rounding of the R’) and the development of a deeper S in I/V6 during s-LBBP, without change in V6RWPT. In the ventricular EGM signal, discrete local ven
tricular potential appears during s-LBBP (blue arrow)—indicating that local myocardium was no longer captured. Modified, with permission by Filip Plesinger.
capture. In patients with narrow QRS or isolated RBBB, V6RWPT alternatively two extra-stimuli delivered during intrinsic rhythm
< 74 ms was 100% specific (albeit only 40% sensitive) for LBB cap (Figure 23). A selective response is diagnostic of conduction system cap
ture, while a cut-off of ≤80 ms was 100% specific in patients with ture, whereas a myocardial response is less clear-cut due to changes in
LBBB, NIVCD, and wide QRS escape rhythm.83 For practical pur QRS morphology which may result from intra-myocardial conduction
poses, cut-offs of <75 ms79 and <80 ms may be used respectively. delay, without initial conduction system capture.
Due to the variability of V6RWPT, with low sensitivity of the cut-
offs, especially in patients with conduction disorders, additional
An algorithm for confirming LBB/fascicular capture in clinical practice
methods are useful to confirm capture in case of prolonged is shown in Figure 27.
V6RWPT. A caveat with V6RWPT is that this parameter was pri It is important to understand that none of the proposed cut-offs are
marily studied in patients with a dominant R-wave in V5/6, and it perfect—even parameters which are described as being 100% sensitive
is unclear if similar cut-offs can be used in case of an rS pattern or specific in studies will have exceptions if the sample size is enlarged.
in these leads. Another aspect is that values vary according to individual patient pro
(3) Measurement of V6–V1 inter-peak interval. This last method is especially files. Thus, a V6RWPT of 75 ms may represent LVSP in a female patient
useful in patients with long V6RWPT due to substantial initial latency with a small heart and normal infra-nodal conduction, whereas a value
or global conduction slowing resulting in false-negative V6RWPT cri of 100 ms in a large patient with dilated cardiomyopathy and bundle
terion. The V6–V1 interval criterion uses a patient-specific reference branch block may indicate conduction tissue capture.
(V1 R-wave peak, reflecting RV activation) to assess LV activation and
is less impacted by conduction system disease than V6RWPT
Acceptable thresholds for LBBAP capture are <1.5 V@0.5 ms (ideally
(Figure 25). The optimal cut-off is >33 ms (which was validated in a < 1 V@0.5 ms) and bipolar sensing should ideally be >4 mV. Capture
separate report84), with a sensitivity of 71.8% and specificity of thresholds may be initially high due to the COI and should be retested
90.0% for LBB capture, whereas > 44 ms was 100% specific.20 A cav after a few minutes.
eat with this parameter is that it was primarily studied in patients with Anodal myocardial capture can lead to transitions in QRS morphology
a dominant R-wave in V5/6, and it is unclear if similar cut-offs can be if threshold tests are performed with bipolar pacing (but should not be
used in case of an rS pattern in these leads. mistaken as proof of conduction system capture); it may in some instances
(4) Sudden increase in V6RWPT ≥ 15 ms at reduced pacing output. This has be desirable as it may shorten the QRS duration.85 The capture threshold
a sensitivity of 82.6% and specificity of 100% for diagnosing loss of LBB for anodal capture should be recorded if it is observed.
capture.20 A value of >10 ms has also been proposed,79 but is within
the range of inter-observer variability for measuring V6RWPT (which
is about 12 ms20). An example is shown in Figure 26. Slitting
(5) Programmed stimulation or burst/ramp pacing can be diagnostic when
threshold testing is non-conclusive. To obtain selective response As with HBP, before slitting the delivery catheter, any other additional
with S2 or S3, it is recommended to use pacing protocols that shorten leads should be implanted to avoid dislodging the LBBAP lead and to
refractoriness of the LBB and prolong refractoriness of the septal provide additional waiting time before retesting the lead. Lead stability
myocardium.80–82 This can be accomplished by a maximally long cycle may be tested before slitting, by gently pulling on the lead or by pushing
of the drive (S1) and then two short-coupled extra-stimuli or and forming an α-shaped loop (see video S8). Paced QRS morphology
A B
LBB ERP

MYO ERP
LBB ERP
MYO ERP
Figure 23 Programmed left bundle branch (LBB) area stimulation. (A) ‘Myocardial’ and selective LBB responses in the same patient. Top panel: fast
drive shortens the refractoriness of septal myocardium; then, long pause (S2) prolongs refractoriness of the LBB; consequently, S3 finds myocardium
excitable but LBB refractory (myocardial response). Bottom panel: slow drive prolongs refractoriness of the myocardium; then, short-coupled S2 short
ens the refractoriness of the LBB; consequently, S3 finds myocardium refractory but LBB excitable (selective response). Reproduced with permission
from Jastrzebski.82 (B) Double extra-stimuli delivered during intrinsic rhythm. Top panel: no change in QRS morphology with S2 coupling interval of
320 ms. Bottom panel: with S2 of 270 ms, a selective response is observed (note: also splitting of the signal in the endocardial channel).
and capture thresholds should be evaluated just before slitting. The stylet insertion funnel (see video S9) or pinch tool (specific accessories
sensed EGM should also be evaluated to check for the presence of a are being developed for this purpose).
myocardial COI and LBB/fascicular potential (if observed initially) to Pros and cons of SDLs vs. lumenless leads are summarized in Table 2.
evaluate perforation or micro-dislodgment.
The slitting tool should lock the lead in place and be maintained
steadily while slitting the sheath. When using SDLs, the stylet should SDLs for His bundle pacing
be partially removed (i.e. 10 cm) to avoid lead dislodgement while According to a recent EHRA survey,88 SDLs are used only by a minority
slitting.86,87 of physicians for HBP. The fixation mechanism of these leads may be
The electrical parameters should be checked again after slitting. relatively easily damaged when they are repositioned after having
been fixated on the fibrous tissue of the His bundle region.89
Considerations with stylet-driven Stylet-driven leads for left bundle area

pacing
pacing leads Most experience with LBBAP has been obtained with lumenless pacing
SDLs differ from lumenless leads, in both lead and helix designs.86 leads.7,52,53,63,90 Recent reports have shown that LBBAP using standard
Firstly, SDLs have an inner lumen for stylet insertion and therefore SDLs is safe and feasible87,91–94 and are being used (exclusively or
present with larger lead diameters (e.g. Abbott Tendril STS and also with lumenless leads) by over half of implanting physicians accord
BIOTRONIK Solia 5.6 F, Boston Scientific Ingevity+ 5.7 F, Microport ing to the EHRA survey.88 Non-randomized single- and multi-centre
Vega 6.0 F). Secondly, stylet insertion makes SDLs stiffer. Thirdly, studies report success rates of 87–95% for LBBAP with SDLs, with
most SDLs have an extendable-retractable helix design whereas lu comparable pacing and electrophysiological characteristics to lumenless
menless leads have a fixed helix design. However, with standard leads, leads.87,92,93 As with lumenless leads, SDLs are positioned using pre-
helix retraction can occur as the outer lead body turns over the inner shaped delivery sheaths. The helix may be kept retracted during map
coil and helix. This can be recognized by an increase in pacing imped ping of the His or the LBBAP lead insertion site (to avoid snagging) or,
ance, as well as by observing the fluoroscopic markers. To avoid helix alternatively, extended. With the helix extended and the stylet fully in
retraction during lead deployment, one should pretension the inner serted, clockwise rotation of the lead body allows to screw SDLs to
coil by additional rotations on the lead pin before locking it with the wards the left-sided septal area. While screwing, keeping the stylet
II
III
aVR
aVL

aVF
V1
V2
V3
V4
V5
V6
LBB
lead
NATIVE CONDUCTION ns-LBBP LV-septal
Figure 24 Native and paced activation times of the left ventricle are equal when the conduction system is captured. LBB potential to V6RWPT is
80 ms, the same as stimulus to V6RWPT during ns-LBBP. In contrast, during loss of LBB capture, stimulus to V6RWPT is >10 ms longer than during
intrinsic activation or ns-LBBP.
ns-LBBP LVSP ns-LBBP LVSP
V6 V6
V1 V1
V1
V2
V3
RV RV
V4
V5
V6
Figure 25 Illustration of effect of ns-LBBP and loss of conduction tissue capture resulting in LVSP with myocardial capture only, on V6–V1 inter-peak
interval, occurring during a threshold test. R-wave peak time in V1 reflects right ventricular activation that depends on transseptal conduction and is not
affected by conduction tissue capture. RWPT in V6 reflects activation of the lateral wall of the left ventricle and is not influenced by loss of septal myocardial
capture. Consequently, a longer V6–V1 interval is observed with left conduction system capture. Modified, with permission, from Jastrzebski et al.20
100
I
II
III
aVR
aVL
aVF
V1
V2
V3

V4
V5
V6
5V@0.5ms 1V@0.5ms
Figure 26 Sudden prolongation of V6RWPT when reducing pacing output during LBBAP implantation, indicating loss of conduction system capture. An
additional lead rotation resulted in conduction system capture threshold of 0.6V@0.5 ms. Note that other changes in QRS morphology are very subtle, and
there is absence of a terminal r or R-wave in V1 despite the presence of conduction system capture.
NO YES
nsLBBP sLBBP nsLBBP LVSP
V1 V1 QRS transition to LVSP or s-LBBP @ threshold test

ns-LBBP ® s-LBBP : splitting of EGM and/or V1RWPT by > 10 ms.
ns-LBBP ® LVSP : V6RWPT by ≥ 15 ms
V6 V6
V6RWPT < 75 ms (native narrow QRS or isolated RBBB)

V6RWPT < 80 ms (LBBB, IVCD RBBB+fascicular block, wide escape rhythm, asystole)
V6
V1 V6 –V1 interpeak interval > 44 ms

LBBP
V6
Potential-V6RWPT = stim-V6RWPT (+/– 10 ms)
V6 V1
STIM
QRS transition to s-LBBP @ programmed stimulation
V6
V6RWPT < 85 ms (native narrow QRS or isolated RBBB)

V6RWPT < 100 ms (LBBB, IVCD, RBBB + fascicular block, wide escape rhythm, asystole)
V6–V1 interpeak interval > 33 ms
Likely LBBP
QRS transition to LVSP @ programmed stimulation
QRS transition with V6RWPT prolongation by 10–14 ms @ threshold test
Qr / QR/ qR in V1
LVSP
V1
DSP
Figure 27 Algorithm for confirming conduction system capture with LBBAP. Some of the steps may be skipped according to operator preference,
experience, or feasibility to perform particular measurements/manoeuvres. DSP = deep septal pacing; IVCD = intra-ventricular conduction delay;
LBBAP = left bundle branch area pacing; LBBB = left bundle branch block; ns-LBBP = non-selective left bundle branch pacing; RBBB = right bundle
branch block; RBBP = right bundle branch pacing; RWPT = R-wave peak time; s-LBBP = selective left bundle branch pacing.
Table 2 Advantages and limitations of lumenless vs. stylet-driven leads for CSP
Lumenless pacing leads Stylet-driven pacing leads (SDLs)

..............................................................................................................................................
Potential Smaller lead body (4.1Fr) might result in less interference with septal Stylet-supported lead body resulting in enhanced stiffness and
advantages kinetics and less risk for collateral damage to septal vessels or torquability, facilitating deep septal lead deployment
septal injury Delivery sheaths with larger diameters offer better support
Isodiametric lead design facilitates septal penetration with less risk of kinking
Fixed helix design: helix is robust and retraction will not occur Wider lead body diameters (>5,5Fr) might offer more grip
In case of LBBP failure, HBP as bail out might be easier than with when rotating the outer lead body
SDL In case of lead dislodgment, standard right ventricular pacing
may be performed without having to regain vascular access

Extendible helix may be kept retracted during mapping and
crossing the annulus, to avoid snagging tissue
Potential Absence of stylet results in less stiffness and torqu ability of the lead Extendable helix design might result in helix retraction during
disadvantages Smaller lead body can result in less grip on the lead when rotating screwing
the lead Higher risk of screw damage with re-positioning with current
Delivery sheaths with smaller diameters might be less supportive SDLs (especially for HBP)
and more prone to kinking Larger lead diameter might increase the risk of collateral
Requirement for new venous access and use of delivery sheath damage to septal vessel, septal injury, or interference with the
for re-positioning (even for conventional position) tricuspid valve
Table 3 Complications with LBBAP and their incidences Table 4 Indicators of septal perforation with LBBAP
Per-operative complications Myocardial COI amplitude

Septal perforation (0.0–14.1%)7,53,63,73,74,87,92,96,98–100 COI < 3–5 mV or absent
Right bundle branch block (19.9% with 6.3% permanent)63 COI ring > tip73
Complete heart block (9.4% acute with 2.6% permanent)63 COI < 25% of V amplitude73
Intra-operative lead dislodgment (3.0%)53 Myocardial COI with QS or RS morphology74
Acute coronary syndrome (0.4–0.7%)7,101
Drop-in unipolar pacing impedance to <450 Ω74 (or by >200 Ω)
Coronary artery fistula (1.4–2.0%)87,92
Worsening of capture/sensing thresholds24,73
Coronary vein fistula/injury96,102
Loss of LBB/fascicular potential23
Septal hematoma103
Helix damage/fracture (0.8–5.0%)87,89,95 Contrast dye leakage into LV with injection via the delivery catheter87
Post-operative complications Overt perforation visualized by lead position/motion on fluoroscopy

Delayed septal perforation (0.1–0.3%)7,87,104,105
Worsening tricuspid regurgitation (7.3–32.6%)53,61–63
Lead dislodgment (0.3–1.5%)7,63,96,98,100,104,106,107
Rise in threshold by >1 V (0.3–1.8%)7,63,96,98,106 entanglement have been described, resulting in helix fracture, elong
Loss of LBB capture (0.3–11.5%)7,63,96 ation, or disuse upon attempts to remove or reposition the
lead.87,89,95 It is advisable to avoid entanglement by not continuing to
rotate the lead if significant torque build-up is felt during lead fixation.
If entanglement is suspected, counter-clockwise rotation and slight
advanced to the tip of the SDL enhances the stability and torquability, traction on the SDL while maintaining tension on the inner lead coil
further facilitating deep septal lead deployment. Most often, stylets with usually untangle the lead. Another concern with SDLs is a possibly high
medium stiffness suffice, although extra-firm stylets can be used if septal er rate of loss of LBB capture than with lumenless leads,96 which may
penetration is difficult. With SDL, unipolar pacing can be applied via the have been due to the learning curve and which needs to be further
stylet, allowing continuous pacing and impedance monitoring while eas evaluated.
ily rotating the lead body.67,86
It is important to partially retract the stylet and sheath (and verify sta
bility) before testing capture thresholds, to avoid confounding measure Peri- and post-operative
ments due to support and extra lead tip contact offered by these tools.
The stiffer lead design of SDLs does not seem to result in more septal
complications
perforations compared to lumenless leads if adequate measures are ta The most frequent complication of HBP is a rise in capture threshold with
ken to timely recognize impending perforation.87,92,93 Cases of SDL loss of conduction system capture (in up to 17% of patients) or requiring
LV Subendocardial Perforation
Tip Ring Tip Ring
15.9 mV
12.8 mV
6.2 mV
3.6 mV
LBBAP

unipolar
unfiltered
50 mm/s 50 mm/s
Figure 28 Current of injury morphology from the LBBAP lead in a patient with the lead in the left ventricular (LV) subendocardial region and in
another patient with septal perforation. In contrast to adequate lead position, with perforation, the COI amplitude from the tip electrode is low
and less than from the ring electrode, with a QR morphology indicating overt perforation (although unipolar capture was still possible here at
1.7 V/0.5 ms, with a pacing impedance of 380 Ω).
Perforation of the interventricular septum has been reported in 0–

14.1% of patients. 7,53,63,74,92,98–100 Unipolar myocardial COI is an im
portant indicator of perforation.23,73,74 Perforation is characterized by
a COI ≤ 2.3 mV (mean 0.9 ± 0.6 mV) while good positions show COI
of approximately 9 mV.24,73 Due to currently limited data, it is difficult
at this stage to define an ideal cut-off that indicates perforation, but in
our experience, when the unipolar tip COI is initially below 3–5 mV,
perforation is to be suspected (the COI may however normally reduce
in amplitude to these levels over the following 10 min and may also be
significantly lower with bipolar sensing). Other useful markers are a COI
< 25% of ventricular electrogram amplitude (sensitivity, specificity, and
positive and negative predictive values of 100%, 94.62%, 28.95%, and
100%) and ring > tip COI amplitude (100%, 98.22%, 57.14%, and
100%, respectively).73 The morphology of the COI may also change
with perforation, with a resulting QS or RS pattern (see Figure 28).24
Other indicators of perforation are shown in Table 4 and include an
acute fall in the pacing impedance < 450 Ω with the 3830 lead (sensitiv
ity 100% and specificity 96.6%)24 or a fall in impedance by >200 Ω86
(although there are currently no published data on this parameter,
this corresponds to the authors’ experience).
Overt perforation is usually straightforward to diagnose, either on
fluoroscopy (see video S10) or due to loss of unipolar COI and cap
ture. It can also be identified by leakage of contrast to the left ven
tricle with injection via the delivery catheter (see video S11).
Micro-perforation (with the screw still partly in contact with excit
able tissue) is however much more subtle to diagnose as capture/
sensing thresholds may be preserved. Careful consideration of the
Figure 29 Micro-perforation of a 3830 lead in the LBB position morphological features described above, unipolar pacing impedance,
with intact electrical parameters. No re-positioning was attempted, and perioperative evolution of pacing thresholds are necessary to
and there were no clinical sequelae. diagnose this complication.
If per-operative perforation is identified, it is important to reposition
the lead (and not simply withdraw it slightly), as dislodgement due to
lead revision (in up to 11% of patients).97 Sensing issues with ventricular the drill mechanism might occur. Acute perforation is asymptomatic
undersensing or His/atrial oversensing may also occur.5 and does not result in any known sequelae if the lead is repositioned.
Complications of LBBAP and their incidences are summarized in Late occurrence of septal perforation has been reported with an inci
Table 3. dence of 0.1–0.3%.7,87,104,105 All cases of overt late perforation should
Indication
Anti-brady pacing CSP-CRT HOT/LOT-CRT
Sinus rhythm Permanent AF Sinus rhythm Permanent AF Sinus rhythm Permanent AF
Additional V lead?1
Y N Y N Y N Y N Y Y
IS-1 RA

IS-1 RA IS-1 RA IS-1 RA
IS-1 RA IS-1 RA IS-1 RA IS-1 RA

IS-1 RA
IS-1 RV IS-1 RV
A A IS-1 RA IS-1 RV
CSP
IS-1 RV IS-1 RV A
PM IS-1 RV
IS-1 RV
CSP IS-1 RV IS-1 RV
IS-1 RV A IS-1 LV A CSP IS-1 RV
RV RV IS-4 LV IS-4 RV
CSP
CSP RV
CSP RV CSP CSP

CSP CSP RV CSP
LV# LV# LV
IS-1 RA IS-1 RA IS-1 RA DF-1 SVC IS-1 RA DF-1 SVC IS-1 RA IS-1 RA
IS-1 RA
DF-4 A A CSP
ICD DF-4 A CSP
DF-4
CSP DF-1 RV IS-1 RV DF-1 RV IS-1 RV A
DF-4
DF-4
IS-1 LA
IS-1 LV IS-4 LV IS-1 LV IS-4 LV
CSP LV 2
RV ICD Iead* RV ICD Iead* RV ICD lead*

RV ICD Iead* RV ICD Iead* CSP
CSP CSP DF-1 ICD LV# DF-1 ICD LV#
RV pin capped RV pin capped
Figure 30 Device configuration for CSP according to device indication, underlying rhythm (i.e. requirement for an atrial lead), presence on an additional
ventricular lead. In all cases with a CSP lead plugged to the RV port, adequate sensing must be ensured. Not shown here are additional configurations with Y
adapters and HOT-CRT with a His lead in combination with an RV lead only (which may be used in case of uncorrected selective His capture with isolated
right bundle branch block111). 1Additional ventricular lead may be indicated for ICD therapy, back-up pacing, adequate ventricular sensing, or CRT opti
mization. 2The LV lead is plugged to the RV port in case the CSP lead does not provide proper sensing (atrial or His potential oversensing and ventricular
undersensing are issues that may be encountered with HBP). *DF-1 ICD lead may also be used; #IS-1 LV lead may also be used. A = atrial; AF = atrial
fibrillation; CRT = cardiac resynchronization therapy; CSP = conduction system pacing; HOT/LOT-CRT = His-optimized or left bundle pacing-optimized
CRT; ICD = implantable cardioverter defibrillator; LV = left ventricle; PM = pacemaker; RA = right atrial; RV = right ventricle.
be managed with lead re-positioning, and if delayed, oral anticoagulation pacing lead implantation,109 although the rise may not be clinically
should be initiated to prevent thromboembolism. meaningful. Septal myocardial injury may also occur during forceful con
Micro-perforation may be diagnosed on post-operative cardiac imaging trast injection. For this reason, it is important that the sheath be pulled
where a portion of the tip of the helix may be exposed to the LV cavity (see slightly off the septum during injection.
Figure 29). If electrical parameters remain stable with low capture thresh Mechanical trauma to coronary vessels is also possible during lead deploy
olds, re-intervention is not warranted. Given the significant variability in the ment. However, acute coronary events (due to direct damage to the septal
thickness of the septum, micro-perforation is likely an underappreciated perforators or coronary artery spasm) are very rarely observed. Myocardial
phenomenon, and although a theoretical risk of thromboembolism is pre infarction manifested with acute chest pain with ST segment elevation has
sent, long-term anticoagulation is not indicated. To date, no reported only been reported in a few cases.7,101,104 Fistula with septal perforators
strokes have been related to this complication. Most likely, prompt en or a coronary venous system and the right ventricle has been described
dothelialization reduces the thrombo-embolic risk. but is rare and has not been reported to have clinical consequences.7
The rate of lead macro-dislodgement is comparable to that of stand Worsening of tricuspid regurgitation is observed in up to a third of
ard RV pacing. In LBBAP, lead tunnelling without forward progression patients61 and is more frequent in patients with basal leads.61,62
into the septum (drill effect), inadequate slack, and neglecting to com Finally, the long-term effects of fatigue on the lead body at the hinge
pletely reposition the lead in the setting of acute perforation will in point proximal to the anode remains a concern.110 The current extrac
crease the risk for dislodgement. Lead micro-dislodgement identified tion experience of 3830 leads implanted in the LBB position is limited to
by loss of HBP/LB capture is probably underappreciated. Loss of ter case reports,110 whereas leads with longer dwell times will likely require
minal R-wave in V1 over follow-up was reported in 4% of patients in special extraction tools.
the MELOS registry.7 This highlights the importance of the 12-lead
ECG at follow-up visits. Correct lead fixation, slitting technique, and ad
equate slack should reduce this likelihood. Requirement for lead re-
positioning should be evaluated on a case-by-case basis. Configurations for device
Mechanical trauma to the septum, unavoidable during transseptal
lead deployment, results in troponin level increase >3× over the nor
connection
mal range in 49.4% of patients. This was less than or comparable to As there are currently no generators dedicated to CSP, the choice of the de
other electrophysiology procedures,108 but higher compared to RV vice and the configuration for lead connection should be chosen according to
house appointments. Most will perform an in-house check 4–8 weeks

Table 5 Advantages and limitations of HBP and of LBBAP post-implantation and then a further in-person check at 6 months.
The 2021 ESC pacing guidelines2 recommend in-person visits every
HBP LBBAP
.................................................................. 6 months with HBP due to the high incidence of late threshold rises
Advantages Advantages
and limitations with automatic capture threshold tests.112 Follow-up
with LBBAP may be more spaced and also rely more on remote de
Maximum electrical synchrony Large target area vice management if capture thresholds are reliably measured by the
Endpoints well-defined for Correction of more distal device.
successful His capture conduction disease Paced 12-lead ECGs are mandatory during in-person follow-up to
Extractability has been Low capture thresholds assess CSP capture and correction of bundle branch block. ECG belts
demonstrated Good sensing parameters can be useful for streamlining follow-up.6
Relatively good mid-term Consistent back-up myocardial Thresholds for conduction system capture, correction of bundle branch
block, and myocardial thresholds should be reported. With LBBAP, it is
evidence for safety and efficacy capture (in addition by anodal
worthwhile checking the QRS width in bipolar as well as unipolar configura

Avoids crossing the tricuspid capture by the ring electrode) tions, as anodal capture may modify the QRS duration in some cases.85
valve when implanted on the No requirement for back-up Absence of atrial oversensing should be verified with HBP.
atrial aspect of the annulus) pacing leads Troubleshooting of CSP and optimization of programming are covered
Some evidence of medium and AV nodal ablation without risk of elsewhere.4,5
long-term lead extraction115,116 compromising lead function
Disadvantages/limitations Disadvantages/limitations
Small target area Conduction tissue capture may be Future perspectives
Capture thresholds may be high difficult to demonstrate in some
CSP has been widely used worldwide using commercially available pa
Sensing issues (atrial and His cases
cing leads and lead delivery systems, and indications are likely to broad
oversensing, ventricular Requirement of digital callipers en in the future.88,113,114 Nevertheless, many aspects of CSP lead
undersensing) (i.e. electrophysiology recording implantation need to be improved. The pacing leads and delivery sys
Limited to correction of system) for measuring parameters tems were not originally designed for CSP, and the implant tools are
proximal conduction block only of conduction system capture not suitable for challenging anatomies. Prototypes are in the pipeline,
Risk if distal conduction block Less electrical synchrony which will no doubt facilitate procedures. Leadless pacemakers de
develops over follow-up compared to HBP, especially in signed for CSP are being developed.
PSAs which simultaneously display selected ECG leads (e.g. I, II, III, V1,
High (up to 11%97) patients with normal baseline
and V6) and EGMs (also unfiltered), with the possibility of performing
requirement for lead revision QRS measurements with digital callipers, would facilitate CSP implantations
Back-up ventricular leads may Complications specific to in centres without an EP recording system.
be indicated in specific transseptal route (septal Generators designed for the purposes of CSP would facilitate pro
situations perforation, lesions to coronary gramming and follow-up and may offer new options such as the ability
Complex programming in case vessels, septal hematoma, etc.) to deliver dual cathodal pacing (tip and ring electrodes) in order that the
of back-up leads Tricuspid regurgitation53,62,63 left bundle and the right ventricle may be captured with fused activation
and better synchrony. Artificial intelligence may serve to identify con
Risk of compromising lead May be challenging in patients with
duction system capture and facilitate testing at implantation and
function with AV node septal scar follow-up.
ablation32,33,117 Limited (but growing) evidence Long-term lead performance and the safety of extraction of the
for safety and efficacy LBBAP lead need to be carefully studied. Specific extraction tools may
Long-term extractability needs to need to be developed. More data from large, randomized clinical trials
be demonstrated with long-term follow-up are required before CSP can be considered
as the optimal pacing therapy and be firmly incorporated in guidelines.
Finally, although LBBAP is overtaking HBP,88 the latter procedure has
advantages which justify its continued use (see Table 5).
the indication: (i) CSP instead of RV anti-bradycardia pacing, (ii) CSP instead of
biventricular pacing, and (iii) CSP combined with ventricular pacing for opti
mizing CRT i.e. His-optimized CRT (HOT-CRT) or left bundle
Conclusions
branch-optimized CRT (LOT-CRT). Further considerations are the require CSP has emerged as being one of the most exciting developments in
ment for an atrial lead (in case of sinus rhythm) and the requirement for add pacing therapy over the last years and is progressively gaining main
itional ventricular lead(s) i.e. for ICD therapy, back-up ventricular pacing, stream clinical practice worldwide. Although limited, the currently avail
adequate ventricular sensing, or hybrid pacing (HOT/LOT-CRT). Figure 30 able data heralds a promising future for this therapy, which should
shows the main combinations which are used. These different combinations nevertheless be implemented in a safe and effective manner.
require adapted programming, which is covered elsewhere.4,5 New tools are very likely to facilitate the procedure, as has been the
case with coronary sinus lead implantation in the past. Nevertheless,
operator skill will remain a requirement to deliver therapy safely and
Follow-up effectively. Standardization of the procedure and proper education
are aspects which will help operators gain that skill to deliver more
While many centres are increasingly utilizing remote pacemaker physiological pacing therapy to their patients. The purpose of the pre
follow-up, the majority of CSP implanters prefer to include some in- sent document is to facilitate that process.
STRENGTH OF ADVICE Symbol HIS BUNDLE PACING Evidence Strength

.................................................................. ..................................................................
Clinical advice, based on robust published evidence Advice TO DO
His bundle capture should always be confirmed OBS
at implantation and follow-up, using validated
criteria46–49 such as transitions in QRS
Clinical advice, based on consensus of the writing group
morphology with decrementing output /
programmed stimulation and comparison of
intervals from His potential and from pacing
May be appropriate, based on published evidence stimulus to V6 R-wave peak.

Screwing of the lead should be continued until OPN
significant torque buildup is felt to ensure lead
May be appropriate, based on consensus of the writing stability
group Lead stability should be routinely assessed43 OBS
Areas of uncertainty
May be appropriate TO DO
In case of infranodal conduction delay or block, OBS
pacing at 400 ms or shorter cycle length
STRENGTH OF EVIDENCE Abbreviation showing 1:1 conduction without aberration
................................................................. should be tested.50
Randomized controlled trials RCT Lead rotations should be pursued until a His OBS
Meta-analysis META current of injury or deep negative
Observational studies OBS morphology is observed, which predicts good
Expert opinion OPN electrical parameters.22,42
Unipolar His capture thresholds should be <2.5 V / OPN
0.5 ms but should ideally aim for ≤1.5 V /
0.5 ms. Bipolar sensing amplitude should be
>2 mV (without atrial/His oversensing)
Tables of advice In the interest of safety, a backup ventricular OPN
lead can be useful in specific situations such as
poor sensing, pacemaker-dependency, high-
grade AVB, infranodal block, high pacing
GENERAL CONSIDERATIONS Evidence Strength threshold and planned AVJ ablation.
..................................................................
Areas of uncertainty
Advice TO DO
Both selective as well as non-selective HBP are OBS
12-lead ECG should be recorded during OPN acceptable and probably have similar
conduction system pacing implantation, ideally outcome although non-selective HBP
using an electrophysiology recording system provides the safety of ventricular backup
for simultaneous endocardial and ECG signals. capture and higher sensing amplitudes.16–19
Endocavitary electrograms with minimally OPN
filtered signals showing current of injury
should be displayed.24,73
May be appropriate TO DO
If an EP recording system is not available, use of a OBS LEFT BUNDLE BRANCH AREA Evidence Strength
PACING
12-lead ECG with a pacing system analyzer ..................................................................
for mapping endocardial signals may be used.7 Advice TO DO
Lead depth should be monitored using different OBS
Advice NOT TO DO
techniques such as fluoroscopy, unipolar paced
CSP implantation should not be performed OPN
QRS morphology and impedance, fixation/
without a minimum display of ECG leads I, II,
III, V1 and V5 or V6.
Continued
Kristina Hermann Haugaa, Prof. Isabel Deisenhofer, Prof. Silvia Priori, Prof.
Continued Markus Stühlinger, Prof. Christian Meyer, Prof. Petr Peichel, Dr. Daniel
Keene, Prof. Jacob Tfelt Hansen, Dr. Luigi di Biase, and Prof. Arthur Wilde.
LEFT BUNDLE BRANCH AREA Evidence Strength
PACING
..................................................................
template beat morphology,71,72 presence of a Document reviewers
23
fascicular potential, current of injury Jean-Claude Deharo (EHRA review coordinator) (France), Bernard
amplitude,24,73 contrast injection via the delivery Thibault (Canada), Frédéric Anselme (France), Wei Hua (China),
catheter and capture by the ring electrode. Michael Glikson (Israel), Francisco Moscoso Costa (Portugal), Jens
Cosedis Nielsen (Denmark), Daniel Keene (United Kingdom), Markus
It is appropriate to evaluate and report presence OBS
Stühlinger (Austria), and Emmanuel Simantirakis (Grece).
or absence of conduction system capture
using validated criteria20,80,83 such as

transition in QRS morphology with
decrementing output/programmed Disclosure
stimulation, V6RWPT, V6-V1 interpeak H.B. has received speaker honoraria, consulting fees, or institutional fel
interval, comparison of intervals from lowship/research support from Abbot, BIOTRONIK, Boston Scientific,
intrinsic potential and from pacing stimulus to Medtronic, and MicroPort. C.I. has received speaker honoraria or con
V6 R-wave peak. sulting fees from Abbot, BIOTRONIK, Boston Scientific, Medtronic and
MicroPort, as well as research support from MicroPort. O.C. has re
Lead entanglement at the insertion site OBS
ceived speaker honoraria and consulting fees from BIOTRONIK,
(characterized by torque build-up) or a ‘drill’ Boston Scientific, and Medtronic, K.C. has received speaker honoraria
effect during screwing (recognized by lack of and consulting fees from BIOTRONIK, Boston Scientific, and
lead progression on fluoroscopy and by pace- Medtronic. J.D.P. reports speaker honoraria and consultancy fees
mapping despite lead rotations) should be from Medtronic, BIOTRONIK, Abbott, and Boston Scientific. J.J. re
recognized to avoid lead damage and ports support from Medtronic (investigator-initiated external research
dislodgement respectively.66
grant) and Boston Scientific (consulting). KV has received speaker hon
oraria, consulting fees, or institutional fellowship/research support
Acceptable thresholds for LBBAP capture are OPN from Abbot, Boston Scientific, Medtronic, and MicroPort. P.V. has
<1.5 V @ 0.5 ms (ideally < 1 V @ 0.5 ms) and the following declarations: Medtronic—speaker, consultant, research,
bipolar sensing should ideally be >4 mV. and fellowship support; Abbott—consultant; BIOTRONIK and
Boston Scientific—honoraria; Patent—HBP delivery tool. Z.W. has re
May be appropriate TO DO ceived speaker honoraria, consulting fees, or institutional fellowship/re
Lead insertion site is evaluated based upon OBS search support from Abbot, Boston Scientific, and Medtronic. The
fluoroscopy in the 20–30° right anterior other authors have not reported any disclosures.
oblique view at 15–35 mm from the His
bundle / tricuspid annulus and using References
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Europace (2023) 25, 1208–1236 EHRA DOCUMENT

EHRA clinical consensus statement

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Received 3 February 2023; accepted after revision 3 February 2023

consensus on which technique to use for implantation and confirmation

* Corresponding author. Tel: +41 22 373 72 00, E-mail address: haran.burri@hcuge.ch

Definitions Left bundle branch pacing

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His bundle pacing

Distal HBP LSFP II +/iso

LBBP LPFP II /III -

55 ms 35 ms 25 ms 0 ms Potential - QRS interval

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ns-HBP ns-RBBP s-RBBP LOC Native latency Paced latency

aVL aVL aVL aVL aVL

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LBBP LFP LVSP

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General considerations His bundle pacing lead implantation

PACING SYSTEM ANALYZER

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Nodal 2:1 AVB

Infra-nodal AVB III + ventricular escape rhythm

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Proximal His Bundle

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myocardium.49 With transitions from ns-HBP to s-HBP, the endocavi­

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Inital deployment After bonus rotations

T = 1.9 V @0.4 ms T = 0.8 V @0.4 ms

ECG confirmation of His bundle capture

Transitions in QRS morphology with æ pacing output Morphological features

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6 Initial Final Initial Final

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lective pacing (s-HBP) widens with shortening of the pulse duration.

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Entanglement Drill Screwdriver

Lead damage or Micro-or macro- Partial or overt

RV septum Deep septum LV septum LBB capture

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¨ Fixation beats of QR/rSR’ morphology during intraseptal

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A Septography via sheath B Pacing from the RING electrode

RV cavity RV endocardium Deep septum

A nsLBBP to LVSP B nsLBBP to sLBBP

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Capture @ 0.5V at 0.5 ms Capture @ 1 V at 0.5 ms

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Considerations with stylet-driven Stylet-driven leads for left bundle area

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NATIVE CONDUCTION ns-LBBP LV-septal

ns-LBBP LVSP ns-LBBP LVSP

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V1 V1 QRS transition to LVSP or s-LBBP @ threshold test

V6RWPT < 75 ms (native narrow QRS or isolated RBBB)

V1 V6 –V1 interpeak interval > 44 ms

myocardium.49 With transitions from ns-HBP to s-HBP, the endocavi