Cardiac Resynchronization Therapy–Defibrillator Implantation with Shock Lead Placement in the Left Bundle Branch Area by Reshaping Steerable Delivery Sheath: A Case Report

There are few reports of establishing cardiac resynchronization therapy-defibrillator with placing a shock lead directly into the LBBA. A 76-year-old woman with heart failure due to dilated cardiomyopathy presented to our cardiovascular medicine department. Despite receiving optimal medical therapy, she had New York Heart Association class III heart failure. While her electrocardiogram showed a sinus rhythm with a left bundle branch block pattern (QRS duration, 160 ms) and left ventricular ejection fraction of 21.0%, holter monitoring revealed frequent multifocal ventricular premature beats and non-sustained ventricular tachycardia. Owing to worsening heart failure symptoms, cardiac resynchronization therapy (CRT)-D implantation was performed. As the Agilis HisPro catheter has two 90° deflections, we reshaped its proximal part to the second deflection and added a septal curve, allowing us to screw the shock lead deep into ventricular septum and achieve QRS narrowing of right ventricular pace (114 ms). The time from stimulus to left ventricular activation was 84 ms. Coronary sinus and right atrial leads were placed in conventional manner. Finally, a defibrillation threshold test confirmed a successful treatment with no postoperative adverse events. Combining left bundle branch area pacing (LBBAP) with coronary sinus (CS) pacing improved prognosis by achieving superior electrical resynchronisation (left bundle branch–optimized CRT: LOT-CRT). However, in the absence of suitable tool for directly placing the shock lead in left bundle branch area (LBBA), it was difficult to establish LOT-CRTD. Herein, we established LOT-CRTD by reshaping Agilis HisPro catheter, which enabled shock lead placement in LBBA.