case_images: PMC11381278_01
case_images: Preparing the lead for extraction. (A) The lead connector and the outer coating of the lead are cut off to expose the inner lumen. (B) The Liberator stylet is advanced to the tip of the lead through the lead lumen. (C, D) A One-Tie compression coil is wound around the lead to bind the Liberator stylet to the body of the lead.
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case_images: PMC11381278_01_fcvm-11-1457025-g001.jpg
case_images: F1
case_images: To ensure secure binding to the locking stylet and the proximal components of the lead, a One-Tie Compression Coil (Cook Medical) was wound around the proximal lead end (Figure 1).
case_images: Intraprocedural fluoroscopy images. (A) Complete distal left subclavian stenosis with collateral drainage to the internal jugular vein. (B) Venoplasty carried out after lead extraction with an Armada peripheral balloon passed along a guidewire over the stenotic segment. (C) A completely inflated Armada peripheral balloon.
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case_images: PMC11381278_01_fcvm-11-1457025-g002.jpg
case_images: F2
case_images: Preprocedural ipsilateral contrast venography revealed a complete occlusion of the left subclavian vein (Figure 2A). The operator then performed a subclavian venoplasty with a balloon for peripheral artery stenosis dilatation (Armada 10.0 mm x 80 mm, 10 atm; Abbot Vascular, Abbott, Santa Clara, CA, USA) (Figures 2B,C). The arterial sheath was then exchanged for a venous one (7F, Biotronik LI-7), and a C315HIS catheter (Medtronic Inc.) was inserted.
case_images: Twelve lead ECG. (A) Ventricular stimulation from a single-chamber pacemaker with atrial sensing (VDD). Atrioventricular synchrony is lost due to atrial undersensing. (B) Left bundle branch area pacing with typical positive lead II+and negative lead III deflection. The QRS duration is 120 ms; the LVAT in V6 is 100 ms; and the V6-V1 interpeak interval is <33 ms:changes due to lead microdislocation. (C) Significant QRS width reduction after implantation at the area of the His bundle. With a unipolar pacing output of 2.5 mV at 1.0 ms, QRS is 90 ms as a result of non-selective His bundle capture. (D) Non-stimulated native ECG recorded after extraction with the QRS duration of 85 ms indicating intact intrinsic conduction after extraction.
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case_images: PMC11381278_01_fcvm-11-1457025-g003.jpg
case_images: F3
case_images: Owing to issues with atrial oversensing observed during follow-up (Figure 3A), it was decided to implant a dual-chamber pacemaker with a conduction system pacing lead. Upon reviewing electrocardiographic (ECG) tracings, it was observed that the initially optimal LBBAP QRS morphology began resembling deep septal pacing (Figure 3B). Consequently, the lead was placed at the distal His position, resulting in non-selective His capture QRS morphology and a greater narrowing of QRS duration (QRS duration at His position, 90 ms) compared with the previous non-optimal LBBAP (QRS duration at LBBAP, 120 ms) (Figures 3B,C).
case_images: Different views to compare lead position in left bundle branch area pacing (left images) and at the area of the His bundle (right images). (A) Lateral view chest x-ray image of the ventricular lead positioned in the LBBAP area. (B) Lateral view chest x-ray image of the ventricular lead in the area of the His bundle (thinner lumenless lead; approximately 2 cm higher than the LBBAP lead). (C) Fluoroscopic antero-posterior view of the ventricular lead positioned in the LBBAP area. (D) Antero-posterior x-ray view of the ventricular lead in the area of the His bundle.
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case_images: F4
case_images: The leads were connected to a permanent pacemaker with an extended battery life (Attesta LDR, MRI SureScan, Medtronic Inc.) (Figure 4).