Permanent His bundle pacing in patients with right atriomegaly: The value of different dedicated delivery sheaths.

ABSTRACT

BACKGROUND: An enlarged right atrium (RA) is a challenging anatomy that can limit the successful use of His bundle pacing (HBP). It is unknown whether new implantation tools could help overcome these challenges. METHODS: Consecutive patients with RA volume index >25 mL/m2 in men and >21 mL/m2 in women underwent permanent HBP. We used a stylet-driven lead (SDL) with an extendable helix delivered via a dedicated delivery sheath (Selectra 3D, Biotronik) as a first attempt. In case of failure, a second attempt was performed with the same lead but with a different delivery curve. Finally, a lumen-less lead (LLL) was also available as a third attempt. RESULTS: The study cohort included 24 patients (median age 75.7 years [interquartile range, 70.9-79.0], 88% men) with a RA volume of 49 mL/m2 (45-54). Using SDL, HBP was achieved with a single sheath curve in 17 patients (71%). The second attempt with the same lead but a different sheath was successful in four more patients (SDL success 87%). The fluoroscopy time increased significantly when the second attempt was necessary (8 min [6-11] vs. 15 min [13-17], p < .001). In the remaining three patients, HBP was further attempted with a LLL leading to a final procedural success of 96%. No lead dislodgment nor significant increase in pacing threshold was observed at 1-month (1.2 [0.7-1.7] V@1.0 ms vs. 1.1 [0.8-1.7] V@1.0 ms, p = .939). CONCLUSION: The availability of different dedicated delivery systems for HBP can improve procedural outcomes even in challenging circumstances, such as in patients with right atriomegaly.