Right-ventricular lead position in cardiac pacemaker implantations and clinical outcomes

Aim:

Pacemaker implantation is a standard procedure in patients requiring cardiac pacing due to AV-block or sick sinus syndrome. Since the latest EHRA recommendations, conduction system pacing, especially left bundle branch pacing (LBBP) should be performed in patients with reduced left ventricular ejection fraction and estimated high percentage on ventricular pacing. 

Therefore the purpose of this study was to analyse feasibility of LBBP in a real-world patient cohort, reduction of QRS width, short-term complications during follow-up and hospitalization. 

Methods: 

We performed a single-centre retrospective analysis form 01/2022 until 04/2025. In total, 555 patients have been implanted with a single or dual chamber pacemaker. Of all patients, 68 (12%) have been implanted with apical RV leads, 187 (33%) with a (mid)-septal position and 33 (6%) with LBBP. 267 patients (48%) have been implanted with apicoseptal position and therefore have been excluded from this analysis

Results: 

In the analysed patient cohort, 112 patients were female (39%), mean age was 74.9 years. Indication for pacemaker implantation was third degree AV-block in 145 patients (40%), second degree AV-block in 46 patients (16%) and sick-sinus syndrome in 66 patients (22%). Our analysis revealed that frequency of LBBP pacing increased, while apical positioning of RV lead was less frequently performed since 2023, in accordance with clinical evidence and EHRA consensus recommendations (figure 1).

Patients receiving LBBP were significantly younger, followed by septal RV-lead position and patients with apical RV electrode being older (67±16 vs. 75±12 vs. 77±10 years; p <0.05 between groups). Baseline-QRS complex duration was 118±34ms in the apical group, and 114±29ms and 127±26ms in the septal and LBBP group, respectively. Stimulated QRS-complex duration was 178±16ms in the apical group vs. 148±18ms in the septal group vs. 118±16ms in the LBBP group (figure 2). 

During follow-up no hospitalization was documented in the LBBP group, while in the apical stimulation group 10 (15%) and in the septal pacing group 12 patients (6%) presented with unplanned hospitalizations for heart failure. 

Conclusion: 

LBBP was performed in younger patients with broader QRS complex at baseline, showing feasibility and a reduced rate of hospitalizations in these patients. Our data indicate that clinical practice changed during the last years showing positive results with respect to stimulated QRS duration. Nevertheless, larger randomized controlled studies are warranted to confirm positive effects on clinical outcome. 



Figure 1: Distribution of RV-lead position by year and lead position. LBBP: left bundle branch pacing

Figure 2: Distribution of QRS width native and stimulated (pre = native; post = stimulated); *** p < 0.001; * p< 0.05). LBBP: left bundle branch pacing