Stepwise Electrosurgical Bailout During Difficult Left Bundle Branch Area Pacing

Electrosurgical energy may facilitate difficult septal lead advancement during left bundle branch area pacing (LBBAP), but procedural feedback after each application is poorly defined. A 63-year-old woman with complete atrioventricular block had persistent left ventricular septal pacing (LVSP) despite deep septal engagement and prolonged mechanical rotation. Two brief 20-W AUTO CUT cycles were delivered through a stylet-driven pacing lead. The first was followed by no meaningful COI or mechanical change. The second was followed by a decrease in COI and renewed lead advancement. Output decrement subsequently demonstrated transition from nonselective to selective LBB capture, with S-V separation of 25 ms and shortening of V6 R-wave peak time from 90 to 73 ms.One-month imaging and electrical parameters remained stable.