Feasibility and safety of left bundle branch area pacing (LBBAP) via an endovascular channel after laser-assisted lead extraction in patients with subclavian vein occlusion: a single-center experience

K. Kuhnhardt (Bad Segeberg)¹, S. Klotz (Bad Segeberg)¹, F. Witt (Bad Segeberg)¹, S. Fichtlscherer (Bad Segeberg)¹, H. Nef (Bad Segeberg)¹, H. L. Phan (Bad Segeberg)^1
1Segeberger Kliniken GmbH Herz- und Gefäßzentrum Bad Segeberg, Deutschland

Background: Left bundle branch area pacing (LBBAP) has emerged as a promising physiological pacing technique. In patients with chronically implanted leads, subclavian vein occlusion poses a significant challenge during device revisions or upgrades, often precluding conventional transvenous access.

Objective: This study aimed to assess the feasibility and safety of LBBAP implantation using an Excimer laser-created venous channel in patients with subclavian vein occlusion. In addition, procedure time, fluoroscopy time, and LBBAP-specific criteria were evaluated in this complex patient cohort.

Methods: We retrospectively analyzed six patients with preoperative phlebography-confirmed complete subclavian vein occlusion who underwent LBBAP for defective lead replacement or system upgrades. All procedures were performed under general anaesthesia with continuous tranesophageal echocardiography (TEE) monitoring and cardiac surgical standby. Venous access was re-established using GlideLight laser sheaths (14/16 French, Philips) with the CVX-300 Excimer Laser System used for transvenous extraction of the dysfunctional leads. In one case, a mechanical rotating sheath was additionally required. All extracted leads were secured with a Lead Locking Device (LLD, Philips) prior to removal. For LBBAP, we used stylet-driven leads (Biotronik, Solia S60) in five cases and a lumenless lead (SelectSecure 3830, Medtronic) in one patient.

Results: All procedures succeeded without complications. Extracted leads had been implanted for 8,2 ± 2,7 years. LBBAP was confirmed by the typical ECG characteristics and was successfully performed in all patients. Mean procedure duration was 104,3 ± 16,3 minutes. Mean dose-area product: 965,9 ± 311,9 cGy·cm². QRS duration decreased from 176,0 ± 37,8 ms to 119,0 ± 6,8 ms post-implantation. Post-implant pacing threshold was 0.54 ± 0.12 V/ms. Sensing amplitude was 9.2 ± 2.0 mV, and lead impedance measured 453.8 ± 60.6 Ω. The mean R-wave peak time (RWPT) in lead V6 was 77.7 ± 10.0 ms, and the V6–V1 interpeak interval was 44.7 ± 3.7 ms. Importantly, all leads were successfully extracted in toto, with no need to abandon or deactivate any leads.

Conclusion:  LBBAP implantation via Excimer laser-created channels in subclavian vein occlusion is technically feasible and safe. To the best of our knowledge, this is the first study to report LBBAP in this specific patient cohort.