Stylet-driven lead fracture in left bundle branch area pacing: a case report

Background: Left bundle branch area pacing (LBBAP) represents an advanced physiologic conduction system pacing technique.However, the long-term stability of stylet-driven leads (SDLs) in LBBAP remains uncertain, with limited documented reports on lead fractures.Case presentation: An 81-year-old male with a history of chronic kidney disease, heart failure, and paroxysmal atrial fibrillation (AF) was admitted for medical management.The patient experienced persistent dyspnea and dizziness attributable to bradycardia and required ongoing rhythm control medication for paroxysmal AF.Given the presence of an underlying left bundle branch block with a mildly reduced left ventricular ejection fraction, a dual-chamber pacemaker (Enitra 8 DR-T; Biotronik, DDDR) with LBBAP using SDL (Solia S50) was implanted.As the patient underwent dialysis via the left arm, pacemaker implantation was performed through the right axillary vein.At 30 months post-implantation, elevated lead impedance exceeding 2,000 and complete ventricular lead dysfunction were highly suggestive of lead fracture despite fluoroscopic imaging showing no definitive evidence of fracture.During ventricular lead extraction, severe adhesions and right axillary vein obstruction were encountered, requiring an 11Fr TightRail device for successful removal.The extracted lead displayed a distinct bend near the interelectrode segment, confirming a typical SDL fracture in LBBAP.Conclusions: This case highlights the typical characteristics of lead fracture and precautions associated with SDL-LBBAP and emphasizes that such fractures can occur beyond previously reported timeframes.To prevent SDL-LBBAP fracture, careful attention to lead manipulation during rotational adjustments is essential during the procedure.