Near zero-fluoroscopy approach to left bundle brunch area pacing for pacing indications during pregnancy: case series

Recent advances in electroanatomic mapping (EAM) and invasive imaging with intracardiac echocardiography (ICE) have led to reduction of radiation exposure in electrophysiological procedures. Recent studies have shown that similar approach could be utilized in conduction system pacing (CSP). However, data for performing CSP in pregnant patients is scarce.

The aim of this case series study was to examine feasibility and safety of performing left bundle branch area pacing (LBBAP) with near zero-fluoroscopy approach in pregnant patients with the indication for permanent pacemaker implantation.

To reduce fluoroscopy 3-dimensional EAM and intracardiac echocardiography system (ICE) was used for relevant anatomy visualisation and lead implantation. Initial mapping and tagging of relevant sites for LBBAP (His bundle area cloud, right ventricular (RV) mid-septum area, and RV apex) on the 3D map was performed from the right femoral vein approach using a 10-polar deflectable diagnostic catheter. The ventricular lead was then connected to the EAM system and navigated to the right ventricular mid-septal area with the aid of ICE. Transseptal lead progression to reach LBBAP was monitored with ICE and confirmed with 12-lead ECG recording system. Atrial lead positioning mainly relied on ICE. Fluoroscopy was only used to determine adequate LBBAP lead slack after sheath removal and after atrial lead positioning, respectively.

Two pregnant patients aged 32 and 34 years with third-degree atrioventricular block were included in this case series. One patient had a structurally normal heart, and the other had a congenitally corrected transposition of the great arteries (CCTGA). Dual-chamber pacemaker implantation with LBBAP was successfully performed in both cases. Average time of fluoroscopy was 30 seconds and radiation dose was 0,62 mGy. Average procedure duration was 85 minutes. There were no periprocedural complications and pacing parameters were stable. However, atrial lead dislocation was recorded in one patient during follow-up, which was repositioned after the patient gave birth.

Near zero-fluoroscopy approach to LBBAP can be safely performed in pregnant patients with or without congenital heart disease. The clinical adoption of this approach requires further validation in larger studies.