Radiation exposure and procedure duration in left ventricular area pacing versus right ventricular pacing: a single-center study

Right ventricular pacing (RVP) has been used for decades to manage bradycardia, however, the myocardial capture results in slow and dyssynchronous activation. Conduction system pacing has emerged as a novel pacing strategy that directly stimulates the heart's native conduction network (1). Left bundle branch area pacing (LBBAP) is the most widely adopted form of conduction system pacing.

LBBAP requires lead placement deep within the interventricular septum, where fluoroscopic guidance is used to monitor lead advancement. This can potentially lead to increased fluoroscopy times and radiation exposure compared to conventional RVP. We retrospectively compared fluoroscopy times and radiation exposure during the implantation of LBBAP and RVP.

We reviewed all pacemaker implantations performed between September 2022 and September 2024, resulting in 740 LBBAP and RVP implantations. All implantations were performed in the same catheterization laboratory using the same fluoroscopy system. The local radiation dose management system was used to collect the total fluoroscopy time, total dose area product, and total air kerma (skin dose estimate) of each procedure, based on the radiation dose structured reports generated by the fluoroscopy system. Additionally, the patient registry was reviewed for the procedure indication, type, skin-to-skin time, and total time in the catheterization laboratory.

Out of the 740 pacemaker implantations, 543 were LBBAP procedures, and 197 were RVP procedures. The total fluoroscopy time, dose-area-product, and air kerma were all significantly different between the LBBAP and RVP procedures (fluoroscopy time 00:05:44 vs. 00:03:47, p<0.001; dose area product 2.1 Gy*cm2 vs. 1.3 Gy*cm2, p<0.001; air kerma 17 mGy vs. 11 mGy, p<0.001). Overall, LBBAP procedures also showed higher variation in fluoroscopy use (Figure 1), dose area product, and air kerma compared to RVP procedures. Skin-to-skin time (Figure 2), and total time in the catheterization laboratory were also significantly different (skin-to-skin time 01:10:00 vs. 00:51:00, p<0.001; total time in cathlab 01:52:00 vs. 01:32:00, p<0.001).

LBBAP procedures result in higher radiation exposure and longer durations compared to RVP. Although radiation doses remain low, cumulative exposure for operators is significant, given the high volume of pacemaker implantations performed. Future efforts should focus on improving fluoroscopy systems and workflows to enhance efficiency and reduce radiation exposure.

Total fluoroscopy time