LBBAP versus conventional CRT reimplantation after transvenous lead extraction: report from a monocentric experience

Abstract Background Cardiac resynchronization therapy – defibrillator (CRT-D) reimplantation after transvenous lead extraction (TLE) can be challenging due to fibrotic remnants and absence of target veins. Left bundle branch area pacing (LBBAP) is emerging as an alternative to conventional CRT, but data is lacking about its feasibility after TLE. Purpose To explore the feasibility and safety of LBBAP as alternative to conventional CRT though epicardial pacing (EP) in patients undergoing CRT-D TLE. Methods We prospectively enrolled all patients admitted for complete CRT-D extraction and replacement from July 2022 to September 2023. At the moment of reimplantation, the choice between EP and LBBAP was made on the basis of posterolateral CS branches viability at post-extraction CS venography. Procedural success was defined as effective stimulation and absence of major complications while the primary endpoints were procedural time, QRS complex duration and electrical lead parameters. Patients undergoing LBBAP and EP reimplantation were compared. Results Twenty-six patients were enrolled (mean age 68.3 ± 7.2 years, p = 0.538; 12% females, p = 0.859). The most frequent cause of device extraction was pocket infection (58%, p = 0.773). Seventeen (65%, p = 0.783) patients had estimated high risk of procedural severe complications measured by EROS score. Overall, 80 leads were extracted. Mechanical extractors and snares were deemed necessary in 35 cases (43%, p = 0.917) and in 2 cases, respectively. Almost all patients (n=25, 96%) underwent right-sided reimplantation. Procedural success was achieved in 24 cases (92%). Compared to standard CRT through EP, LBBAP reimplantation accounted for a faster procedure (109.5 ± 34.2 vs. 126.5 ± 46.8 min; p = <0.001), less radiologic exposure (877.0 ± 234.6 vs. 1332.0 ± 515.1 sec, p <0.001) and better ventricular pacing thresholds (0.7± 0.1 vs. 1.8± 0.6 V, p <0.001). Despite a similar pre-extraction paced QRS duration (127.4 ± 13.8 vs. 133.0 ± 14.4 msec; p = 0.610), LBBAP reported significant improvement in final QRS duration (105.0 ± 13.1 vs. 127.1 ± 10.4 msec, p < 0.001) with major reduction in QRS duration (- 10.9 ± 7.5 vs - 6.8 ± 10.1, p < 0.001). Conclusion After a CRT TLE procedure, LBBAP reimplantation accounted for lower procedure duration, lower radiologic exposure, narrower QRS and lower ventricular pacing thresholds, demonstrating to be a valuable alternative to EP.