Outcome of septal vascular injury and perforation in left bundle branch area pacing: Evaluating septal integrity using an institutional protocol.

Abstract

Background: Left bundle branch area pacing (LBBAP) involves deep septal lead deployment to capture the left bundle branch or adjacent myocardium, which could compromise the septum's structural integrity or pose injury to the septal vasculature. The potential long-term effects of these complications remain unclear.

Objective: This study aimed to evaluate acute and long-term outcomes of septal injury during LBBAP using a structured institutional protocol.

Methods: Adult patients receiving LBBAP between March 2019 and October 2024 were assessed for septal complications, including septal perforation, septal venous channel perforation (SVCP), septal coronary artery fistula (SCAF), and septal hematomas. The protocol included intraprocedural septography and postprocedural echocardiography, including visual assessment and strain imaging, to assess global and septal kinetics.

Results: Of 636 patients, 32 (5%) experienced septal complications: 26 septal perforations (4%), 3 SVCPs (0.5%), and 3 SCAFs (0.5%). All perforations and SVCPs were identified during implantation, whereas SCAFs were diagnosed postprocedurally. All complications were asymptomatic with no adverse clinical outcomes. Septal kinetics remained unaffected as peak septal strain values showed no significant differences before and after implantation (from 20.4% ± 3.6% to 21.3% ± 3.3%; P = .16). No late perforations or ventricular septal defects were observed. Two SCAFs healed spontaneously, and 1 persisted asymptomatically. Key pacing characteristics and left ventricular ejection fraction remained stable throughout follow-up.

Conclusion: Septal perforations are the most frequent septal complication and are easily detected. Septal vascular injuries can be detected by dedicated protocols but occur rarely. None of these complications compromised septal integrity or function.