Received: 5 November 2019 | Revised: 13 December 2019 | Accepted: 23 December 2019

DOI: 10.1111/jce.14352

ORIGINAL ARTICLE

Programmed deep septal stimulation: A novel maneuver for

the diagnosis of left bundle branch capture during permanent
pacing

Marek Jastrzębski MD, PhD1 | Paweł Moskal MD1 |

Agnieszka Bednarek MD, PhD1,2 | Grzegorz Kiełbasa MD1 |
Aleksander Kusiak MD, PhD1,2 | Tomasz Sondej MD, PhD1 |
Adam Bednarski MD, PhD1 | Pugazhendhi Vijayaraman MD, FHRS2 |
Danuta Czarnecka MD, PhD1

1
First Department of Cardiology,
Interventional Electrocardiology and Abstract
Hypertension, Jagiellonian University Medical Introduction: Permanent deep septal stimulation with capture of the left bundle
College, Kraków, Poland
2 branch (LBB) enables maintenance/restoration of the physiological activation of the
Geisinger Heart Institute, Geisinger
Commonwealth School of Medicine, left ventricle. However, it is almost always accompanied by the simultaneous
Wilkes‐Barre, Pennsylvania
engagement of the local septal myocardium, resulting in a fused (nonselective) QRS
Correspondence complex, therefore, confirmation of LBB capture remains difficult.
Marek Jastrzębski, MD, PhD, First
Methods: We hypothesized that programmed extrastimulus technique can differentiate
Department of Cardiology, Interventional
Electrocardiology and Hypertension, nonselective LBB capture from myocardial‐only capture as the effective refractory
Jagiellonian University Medical College, ul.
period (ERP) of the myocardium is different from the ERP of the LBB. Consecutive
Kopernika 17, 31‐501 Kraków, Poland.
Email: mcjastrz@cyf-kr.edu.pl patients undergoing pacemaker implantation underwent programmed stimulation
delivered from the lead implanted in a deep septal position. Responses to programmed
Disclosure: Dr. Jastrzebski: consultant and
speaking fees from Medtronic and Abbott. Dr. stimulation were categorized on the basis of sudden change in the QRS morphology of
Vijayaraman: honoraria, consultant, research—
the extrastimuli, observed when ERP of LBB or myocardium was encroached upon, as:
Medtronic; advisory board, consultant—
Boston Scientific; consultant—Abbott, Biotro- “myocardial,” “selective LBB,” or nondiagnostic (unequivocal change of QRS morphology).
nik, Merritt Medical; and patent pending for
Results: Programmed deep septal stimulation was performed 269 times in 143
His delivery tool. Other authors: No disclo-
sures. patients; in every patient with the use of a basic drive train of 600 milliseconds and in
126 patients also during intrinsic rhythm. The average septal‐myocardial refractory
period was shorter than the LBB refractory period: 263.0 ± 34.4 vs 318.0 ± 37.4 milli-
seconds. Responses diagnostic for LBB capture (“myocardial” or “selective LBB”) were
observed in 114 (79.7%) of patients.
Conclusions: A novel maneuver for the confirmation of LBB capture during deep
septal stimulation was developed and found to enable definitive diagnosis by
visualization of both components of the paced QRS complex: selective paced LBB
QRS and myocardial‐only paced QRS.

KEYWORDS
effective refractory period, electrocardiogram, left bundle branch pacing, nonselective capture,
refractoriness

J Cardiovasc Electrophysiol. 2020;31:485–493. wileyonlinelibrary.com/journal/jce © 2020 Wiley Periodicals, Inc. | 485

486 | JASTRZĘBSKI ET AL.

1 | INTRODUCTION where proper deep septal lead deployment was possible. Lead
behaviors during deep septal deployment, characterized by us
Permanent deep septal pacing with direct capture of the left bundle elsewhere,10 were used to guide lead positioning and fixation. The
branch (LBB) is a new promising pacing option with a potential area located approximately 2 to 3 cm apically from the distal HB site
application for both bradyarrhythmia and heart failure treatment.1–6 was targeted; preferentially characterized by paced QRS morphology
During deep septal pacing it is important to ensure that the LBB or its in V1 showing notch near the S wave nadir (“W” morphology)
proximal fascicles are truly captured. In the vast majority of deep and/or being slightly narrower than the paced QRS from neighboring
septal pacing cases, LBB capture is accompanied by the simultaneous sites and with normal axis in the frontal plane (R in lead I, Rs in lead II,
engagement of the local septal myocardium, resulting in nonselective and rS in lead III). Lead deployment was performed under
(ns) LBB capture as the predominant form of ventricular activation fluoroscopic and electrocardiogram (ECG) guidance. Constant or
with this pacing modality. Both LBB capture QRS and deep septal‐ interrupted pacing from the lead was delivered to monitor change in
myocardial capture QRS are usually relatively narrow and of right the paced QRS morphology during screwing‐in. We aimed to obtain
bundle branch block morphology. Therefore, during electrocardio- paced QRS with an r′ deflection in lead V1, record LBB potential and/
graphic assessment of ns‐LBB pacing, it is not immediately apparent or observe evident QRS narrowing as compared with the initial right
if direct LBB capture was achieved or just septal‐myocardial capture ventricular septal paced QRS. If after 5 to 8 lead turns, a typical
is present. progressive change of paced QRS morphology was not observed or
A similar issue is present during His bundle (HB) pacing, however, early strong counterclockwise torque build‐up in the lead was
diagnosis of HB capture, in most cases, can be easily established present,10 the lead was repositioned. This implantation technique
using differential pacing output—a maneuver based on differences in was similar not only to the recently described approach to LBB
capture thresholds between the His‐Purkinje system (HPS) and the pacing by Huang et al4 but also to the left septal pacing method
7,8 2
myocardium. During deep septal pacing this method often fails, as developed by Mafi‐Rad at al.5
capture thresholds of LBB and of the adjacent myocardium are Programmed stimulation was performed when the final deep
usually very similar. Therefore, new methods/criteria for diagnosis of intraseptal lead position was reached. The pacing output was set at
LBB capture are needed. two times the capture threshold and the lead was connected to a
Programmed HB stimulation, a technique that exploits differ- universal heart stimulator (UHS 3000; Biotronik, Germany) in a
ences in effective refractory period (ERP) between HB and septal unipolar pacing configuration. Premature beats were introduced
myocardium, was shown to be capable of providing definite after an 8‐beat basic drive train of 600 milliseconds and also during
diagnosis of HB capture during ns‐HB pacing by visualizing the intrinsic rhythm (when present). The coupling interval was
components of the fused paced QRS complex, that is, myocardial decreased in 10‐millisecond steps, starting from 400 to 450 milli-
capture QRS and/or selective HB capture QRS.9 We hypothesized seconds (or longer if the QRS of the first premature stimulus was not
that programmed stimulation will be able to provide definitive identical as the QRS of the drive train), until the complete loss of
diagnosis of LBB capture in a similar fashion; this was never capture. Responses to programmed stimulation were analyzed with
investigated before. the use of an electrophysiology system (Lab System Pro; Boston
Scientific) using a sweep speed of 50 to 100 mm/s and categorized
according to the principle delineated below. Theoretically, when the
2 | AIM septal‐myocardial ERP is shorter than the LBB ERP, the first
extrastimulus delivered at a coupling interval shorter than the LBB
To analyze responses observed during programmed deep septal ERP should result in a QRS widening revealing QRS morphology of
stimulation in regard to the diagnosis of LBB capture. pure myocardial capture; while in cases where the septal‐myocardial
ERP is longer than the LBB ERP, the first extrastimulus with a
coupling interval shorter that septal‐myocardial ERP should be
3 | METHODS followed by selective LBB paced QRS complex. Both responses would
be diagnostic of nonselective pacing and, consequently, would
This was a single‐center prospective study: consecutive patients who confirm that LBB capture was achieved.
received HPS pacing devices were screened and patients with pacing Changes in the paced QRS morphology from ns‐LBB into
lead deployed deep intraseptally, to capture LBB, were included. To selective LBB or myocardial QRS during increase/decrease in pacing
achieve deep septal pacing, a thin (4.1F), active helix, screw‐in pacing output (differential pacing output maneuver) were analyzed in every
lead (model 3830; Medtronic) was positioned with the help of a patient. The QRS complex morphologies obtained during this
delivery sheath (Medtronic models C315His, C304XL, and C315S10, maneuver were compared (pairwise) with QRS complexes obtained
depending on the heart anatomy). The HB potential (if recorded) or with programmed stimulation.
the most superior aspect of the tricuspid annulus, appraised All patients gave written informed consent for participation in
electrophysiologically and fluoroscopically, were used as anatomical this study and the Institutional Bioethical Committee approved the
landmarks. We aimed at any basal to mid‐interventricular septal site study protocol.
JASTRZĘBSKI ET AL. | 487

4 | RES U LTS and also when possible during intrinsic supraventricular rhythm (126
times).
4.1 | Population Responses observed during programmed LBB stimulation were
categorized as follows:
Out of 412 consecutive patients that underwent HPS pacing device
implantation within 1 year, 163 patients received deep septal 1. Diagnostic response type 1 (“myocardial,” Figure 1, left panel):
pacing lead, 143 of which had programmed stimulation performed change of paced QRS into a myocardial‐only paced QRS, that is
in a standardized fashion at the time of implantation and were evidently broader, often with slur/notch/plateau instead of a
included in the current study. These deep septal/LBB pacing cases pointy R wave peak and/or with obvious change in amplitude/
represent patients in whom attempt to implement HB pacing polarity in several leads.
(primary pacing strategy in our center) was unsuccessful, suboptimal 2. Diagnostic response type 2 (“selective LBB,” Figure 1, right panel):
(high threshold, poor sensing, etc.), or troublesome. Clinical‐ and change of paced QRS morphology to a selective QRS of right
pacing‐related characteristics of the studied patients are presented bundle branch morphology preceded by a latency interval.
in Table 1. 3. Nondiagnostic response: recognized when neither diagnostic
response type 1 nor type 2 is present. During nondiagnostic
response, progressive QRS prolongation and only minor ampli-
4.2 | Programmed stimulation tude change are observed when the extrastimuli encroach on the
relative refractory period of the myocardium (final 1‐3 coupling
Programmed deep septal stimulation was performed 269 times: 143 intervals before ERP is met).
times with the use of an 8‐beat basic drive train of 600 milliseconds
A total of 114 (79.7%) patients showed diagnostic response;
“selective LBB” response was observed in 44 patients while
T A B L E 1 Basic clinical characteristics of the studied group
(n = 143) “myocardial” response in 107 patients. Both myocardial and selective
responses, that is, visualization of both components of the fused ns‐
Age, y 76.1 ± 11.8
LBB QRS, was possible in 37 (25.9%) patients. In all these cases, the
Male gender 77 (53.8%)
selective LBB paced QRS and selective myocardial paced QRS were
Pacing indication, n
compatible with each other with regard to the morphology of the ns‐
Sick sinus syndrome 30 (21.0%)
LBB paced QRS (Figure 2). Selective response was much more often
Atrioventricular block 65 (45.4%)
Atrial fibrillation with bradycardia 20 (14.0%) seen when premature beats were introduced during the intrinsic
Heart failure 28 (19.6%) rhythm rather than after the basic drive train, 43 (30.1%) vs 2 (1.4%),
Comorbidities, n respectively. While myocardial response was more often seen when
Heart failure 58 (40.8%) premature beats were introduced after the basic drive train rather
Coronary heart disease 55 (38.5%) than during the intrinsic rhythm, 104 (72.7%) vs 33 (23.1%),
Diabetes mellitus 61 (42.7%)
respectively. Presence of LBB block during intrinsic rhythm did not
Hypertension 122 (85.3%)
Severe valvular disease 19 (13.5%) influence observed responses to programmed stimulation.
The average septal‐myocardial refractory period was significantly
Native QRS duration, ms 127.2 ± 30.8
shorter than the LBB refractory period: 263.0 ± 34.4 vs 318.0 ±
Baseline QRS morphologies, n
Narrow QRS 45 (31.5%) 37.4 milliseconds; P < .01 and 293.1 ± 56.5 vs 355.5 ± 69.8 millise-
Right bundle branch block 17 (11.9%) conds; P < .0001, when assessed with the 600‐millisecond drive train
Right bundle branch block + LAH/LPH 26 (18.2%) or with extrastimuli delivered during supraventricular rhythm,
NIVCD 13 (9.1%) respectively. In patients with LBB block, there was tendency for
Left bundle branch block 14 (9.8%)
longer ERP: 317.2 ± 36.8 vs 338.7 ± 28.0 milliseconds; P = 0.11.
Asystole/broad slow escape rhythm 16 (11.2%)
LV ejection fraction, % 50.9 ± 14.3
LV end‐diastolic dimension, mm 50.5 ± 8.2
4.3 | Differential pacing output maneuver
Paced QRS duration,* ms 111.9 ± 15.1
Left bundle branch potential visible, n 58 (40.6%) QRS morphology change during decreasing/increasing pacing output was
Ventricular sensing, mV 9.0 ± 5.1 observed in 27 (18.9%) patients. In 22 (15.4%) cases, selective QRS was
Capture threshold, V 0.6 ± 0.3 revealed (myocardial threshold > LBB threshold) while in 5 (3.5%) cases,
myocardial QRS was revealed (myocardial threshold < LBB threshold). In
Abbreviations: HB, His bundle; LAH, left anterior hemiblock; LPH, left
posterior hemiblock; LV, left ventricular; NIVCD, nonspecific intraven- all these cases, difference in capture thresholds was small, and,
tricular conduction delay; ns, nonselective. consequently, change of QRS morphology was observed briefly—just
*Measured from real QRS onset rather than from the pacing spike. before complete loss of capture. In all patients in whom LBB capture was
488 | JASTRZĘBSKI ET AL.

F I G U R E 1 Two types of diagnostic responses to programmed deep septal pacing observed in the same patient. Left panel: extrastimulus
delivered after a basic drive train of 600 milliseconds results in a myocardial response. Note the loss of right bundle branch pattern in lead V1,
QRS prolongation, and loss of pointy R wave peak—both most evident in leads I, II, and aVR. Right panel: extrastimuli delivered during intrinsic
supraventricular rhythm, first results in an ns capture and the second with a 10 milliseconds shorter coupling interval results in a selective LBB
capture. Note isoelectric interval before QRS, augmentation of right bundle branch morphology in lead V1 and opposite polarity of QRS in leads
III and V6 as compared leads to the “myocardial” response. Paper speed 25 mm/s. LBB, left bundle branch

confirmed by the differential pacing output, the programmed pacing also 5.1 | Myocardial QRS response during programmed
provided diagnostic response; the QRS complexes obtained by both stimulation
techniques were found compatible in all cases.
The current study shows that during ns pacing extrastimuli with
short coupling interval (usually <300 milliseconds) results in changes
4.4 | Presence of LBB potential of paced QRS morphology due to the selective myocardial capture,
that is, loss of HPS capture. Such a QRS response was determined by
In 58 (40.6%) patients LBB potential was discernible on the deployed ERP of the HPS being longer than ERP of the myocardium.
deep septal lead. Programmed stimulation delivered diagnostic Careful analysis of paced QRS morphology is crucial for the
response in 52 (89.6%) of these patients vs 62 (72.9%) of patients diagnosis of pure myocardial capture; sometimes changes from ns‐
without LBB potential (P = .019). LBB to myocardial QRS are very obvious, but at times relatively
subtle. Moreover, the spectrum of myocardial QRS morphologies
is wider during the loss of LBB capture than what is seen during
5 | D IS C U S S IO N the loss of HB capture. This is determined by a wider spectrum of
pacing lead positions both in superior‐inferior (QRS axis) and
The major finding of the current study is that programmed deep basal‐apical (precordial transition) orientation and also with
septal stimulation could reveal one or two components of the fused regard to the depth of penetration into the interventricular
paced QRS complex and thus, confirm LBB capture in the majority of septum (left or right bundle type QRS configuration). Our current
deep septal pacing cases. This was possible due to the differences in observations suggest that change from ns‐LBB to myocardial QRS
refractoriness between LBB and myocardium. This is the first study usually results in a rightward (inferior) axis shift, stronger anterior
that determined ERP of the human LBB in a large group, with findings forces (higher amplitude in precordial leads V2‐V5), loss/decrease
consistent with a prior report of two cases.11 in amplitude of r′ in V1 (QS configuration), longer global QRS
JASTRZĘBSKI ET AL. | 489

Interestingly, the myocardial response during programmed LBB

stimulation was observed less frequently than during programmed
HB stimulation (74.8% vs 100%).9 This might be related to the lower
percentage of cases with HPS capture during deep septal pacing as
compared with HB pacing. However, a nondiagnostic response was
also observed in cases with a bona fide LBB capture (nondiagnostic
response with extrastimuli delivered during intrinsic rhythm yet
diagnostic response with extrastimuli delivered after a drive train
and vice versa). Perhaps the occasional lack of myocardial response
during ns‐LBB capture can be also explained by a smaller difference
between ERPs of HPS and adjacent myocardium during LBB pacing
as compared with HB pacing, 55 vs 81.9 milliseconds, respectively.9
This gives a smaller “opportunity” for the extrastimuli to capture only
the adjacent myocardium. It is also possible that in some cases the
myocardial QRS and ns‐LBB QRS are too similar and the loss of HPS
capture is difficult/impossible to establish by analysis of changes of
QRS morphology. Moreover, in some cases, even myocardial capture
might result in a relatively fast engagement of the septal HPS limiting
the difference between myocardial paced QRS and ns‐LBB
paced QRS.

5.2 | Selective LBB QRS response during

programmed stimulation
F I G U R E 2 Three cases illustrating that programmed deep septal
pacing can visualize both components of the NS left bundle branch
A paced QRS with an isoelectric interval preceding it is considered an
paced QRS that are morphologically compatible. The NS left bundle
branch QRS results from fusion of the SEL left bundle branch QRS unmistakable diagnostic hallmark of selective HPS capture. Selective
and the MYO‐only paced QRS. This can be best appreciated by LBB QRS during programmed stimulation was almost exclusively
analyzing QRS in leads II and V6. Note QRS changes typical for loss seen when premature stimuli were delivered during intrinsic rhythm.
of LBB capture: inferior axis shift and increase in QRS amplitude in This is because during native supraventricular rhythm HPS is always
precordial leads. Paper speed 25 mm/s. LBB, left bundle branch;
depolarized earlier than the adjacent myocardium. Consequently,
MYO, myocardial; NS, nonselective; SEL, selective
when an HPS extrastimulus is delivered during supraventricular
rhythm, the HPS might be already excitable while the myocardium is
duration, delayed R wave peak in V6, notches and rounded/ still refractory (Figure 3). This phenomenon enables to obtain
slurred R wave peaks (Figures 1, 2, 4, and 5). These last selective QRS during programmed stimulation even in cases when
observations are analogous to what we have reported for the ERP of HPS is longer than myocardial ERP.9 However, a selective
right ventricular septal‐myocardial QRS during loss of HB response to programmed stimulation was observed in only 30.8% of
capture.12 cases. This is may be explained by a relatively small difference in local
When analyzing deep septal paced QRS morphology additional activation times (HPS vs adjacent myocardium), that is rarely bigger
data might be useful to diagnose change from ns‐LBB capture into than the difference in ERP between HPS and myocardium at the
myocardial QRS. First, the QRS axis of the myocardial QRS is pacing lead site; this stands in contrast to the observations during
determined by the pacing lead position while the selective QRS programmed HB stimulation.9 The LBB is activated 20 milliseconds
axis depends solely on the HPS activation. Therefore, the more later than the HB, while the mid‐interventricular septum on the left
superior location of the pacing lead on the septum, the more side is activated very early—earlier than the myocardium near the
positive QRS in II, III aVF is to be expected with loss of HPS HB. Consequently, the difference in local activation times between
capture. Second, the myocardial QRS morphology should be HPS and adjacent myocardium is less during LBB pacing than during
compatible with the nonselective and selective QRS morphologies HB pacing.
in a particular case—according to the rules of QRS fusion. For
example, when the ns‐QRS in lead II has RS configuration and
selective QRS has rS/QS configuration (due to the often seen 5.3 | Clinical translation
preferential activation of the posterior fascicle), then the myo-
cardial QRS must have R/Rs configuration in this lead Regardless of the final implemented pacing mode (HB pacing or LBB
(Figures 1 and 2). pacing), it is our current policy to confirm HPS capture with the same
490 | JASTRZĘBSKI ET AL.

F I G U R E 3 During native
supraventricular rhythm with intact
conduction in the LBB, the LBB is always
depolarized earlier than the adjacent
myocardium. Consequently, when an
extrastimulus is delivered during
supraventricular rhythm the LBB has more
time to recover (354 milliseconds in the
current example) and might be already
excitable while the myocardium has less
time to recover (296 milliseconds in the
current example) and might be still
refractory. This phenomenon enables to
obtain selective QRS during programmed
pacing even in cases when effective
refractory period of LBB is longer than the
myocardial effective refractory period. P,
LBB potential; LBB, left bundle branch

F I G U R E 4 During deep septal pacing a relatively wide QRS and without r′ in V1 was obtained (left panel) in this case. Uncertainty as to the
LBB capture were addressed during follow‐up by temporary reprogramming to asynchronous mode (VOO 45 bpm; right panel). This promptly
resulted in visualization of selective (sel) LBB paced QRS—occurring always with critical coupling of the pacing spikes. Consequently,
nonselective (ns) LBB capture was diagnosed and the unusually large myocardial component in the ns‐LBB QRS was attributed to the relatively
shallow lead penetration into the interventricular septum. Note that the first pacing stimulus (marked “ns”) with longer coupling interval results
in QRS identical as during regular pacing (marked “ns‐LBBP”), while the last stimulus (marked “ref”) results in noncapture due to coupling
interval shorter than effective refractory period of both LBB and myocardium. Paper speed 25 mm/s. LBB, left bundle branch
JASTRZĘBSKI ET AL. | 491

F I G U R E 5 This is a collage of QRS complexes taken from a continuous electrocardiogram (ECG) recorded as the lead was progressively
deeper deployed into the interventricular septum without interruption of pacing (“pacemapping during screwing‐in”). During this 25‐second‐
long ECG there was a continuous, smooth QRS transition (circles) from the wide, right ventricular paced QRS (on the left) to the narrow, sharp
QRS with r′ in V1 of the left bundle branch capture morphology (on the right). Note the transition of the V1 notch to the end of QRS and then
transformation of it into r′ of growing amplitude. Despite careful analysis of all transitional QRS complexes there was not a single moment when
occurrence of left bundle branch capture could be pinpointed

methods: programmed stimulation and differential pacing output noninvasive electrophysiology study option might be used and/or the
maneuvers. In our experience, these maneuvers can be easily pacemaker can be temporarily reprogrammed to a slow asynchro-
incorporated into a standard implantation protocol. During LBB nous pacing (VOO), resulting in a variable coupling intervals with the
pacing quite different responses with these maneuvers are observed intrinsic QRS complexes. This usually promptly results in variability
than during HB pacing. During LBB pacing equal capture thresholds of paced QRS morphology, providing evidence of LBB capture
are common (75% of cases vs 8%‐10% when compared with HB (Figure 4).
pacing) resulting in a much lower diagnostic yield of the differential Programmed deep septal stimulation enables to overcome the
pacing output. Consequently, when LBB pacing is implemented, limitations of criteria based on paced QRS complex morphology as
programmed stimulation technique plays a more important role to most likely there is a substantial overlap between QRS morphol-
confirm HPS capture. ogy of deep septal‐myocardial paced QRS and ns‐LBB paced QRS.
Programmed deep septal stimulation can be also applied using Parallel situation is present during HB pacing where both QRS
different protocols (not analyzed in the current study), shorter drive duration and V6 R wave peak time values show typical Gaussian
train or double extrastimuli during intrinsic rhythm might augment distribution with a significant overlap between myocardial capture
the difference in ERPs better and hence provide a diagnostic and ns‐HB capture.12 Interestingly, programmed deep septal
response when protocols studied by us fail. Other modifications of stimulation shows that direct LBB capture can be present despite
the pacing method might be more suitable or practical in some a relatively wide‐paced QRS complex, lack of LBB potential on the
settings, for example, during device follow‐up the implemented pacing lead electrogram, and even lack of r′ in lead V1 QRS
492 | JASTRZĘBSKI ET AL.

(Figure 4). This suggests that the currently proposed arbitrary 6 | CO NCL USIONS
2,4
criteria for LBB capture might not be very sensitive. Current
results suggest that the presence of LBB potential might be very Diagnostic responses observed during programmed stimulation
specific (specificity > 89.6%) for LBB capture, however, it is not too reassures the implanting electrophysiologist that the acute goal of
sensitive (sensitivity of approximately 46%, assuming high sensi- the procedure was achieved. This might be especially useful when
tivity of programmed deep septal stimulation). Perhaps LBB other LBB capture criteria are not fulfilled. Visualization of both
capture is already achievable at a substantial distance from the myocardial paced QRS and selective LBB in patients with obligatory
LBB and that from a practical point of view, LBB capture is not an ns‐LBB pacing provides insights with respect to the HPS activation
“all or nothing” phenomenon. We believe that the contribution of and myocardial activation patterns in a particular case. Diagnostic
the LBB capture and myocardial capture to the ns‐LBB QRS can potential of programmed stimulation in patients with permanent
vary depending on the depth of penetration of the pacing lead into conduction system pacing deserves further investigation.
the interventricular septum—the more shallow the lead position
the bigger contribution of direct myocardial capture. This is
ORCI D
supported by the observation that during constant pacing from the
pacing lead, throughout deployment into the interventricular Marek Jastrzębski http://orcid.org/0000-0002-3318-6601
septum (“pacemapping while screwing‐in technique”), the QRS Paweł Moskal http://orcid.org/0000-0001-5644-5963
transition from a right ventricular paced QRS to a ns‐LBB QRS is Pugazhendhi Vijayaraman http://orcid.org/0000-0003-2230-100X
continuous, rather than sudden (Figure 5).6

R E F E R E N CE S

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2. Vijayaraman P, Subzposh FA, Naperkowski A, et al. Prospective
patient inclusion and interpretation of ECG results.
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This could influence interpretation of responses, however, only in a 3. Li X, Li H, Ma W, et al. Permanent left bundle branch area pacing for
atrioventricular block: feasibility, safety, and acute effect. Heart
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output).
5. Mafi‐Rad M, Luermans JG, Blaauw Y, et al. Feasibility and acute
Nondiagnostic response to programmed stimulation was ob- hemodynamic effect of left ventricular septal pacing by transvenous
served in 20.3% of studied cases. It is not known if these cases approach through the interventricular septum. Circ Arrhythm Electro-
represented myocardial capture only or also LBB capture with physiol. 2016;9:e003344.
6. Jastrzebski M, Moskal P, Bednarek A, Kielbasa G, Czarnecka D. First
nondiagnostic response for some reason. This limits the practical
Polish experience with permanent direct pacing of the left bundle
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However, currently there is no gold standard method that we could 7. Vijayaraman P, Dandamudi G, Zanon F, et al. Permanent His bundle
use to confirm, with high specificity and sensitivity, LBB capture and/ pacing: recommendations from a Multicenter His Bundle Pacing
Collaborative Working Group for standardization of definitions,
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during our previous study regarding programmed stimulation during Czarnecka D. His bundle has a shorter chronaxie than does the
conduction system pacing. This showed that there is no sudden QRS adjacent ventricular myocardium: implications for pacemaker pro-
gramming. Heart Rhythm. 2019;16:1808‐1816. https://doi.org/10.
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This study was performed by the operators with substantial Czarnecka D. Programmed His bundle pacing. Circ Arrhythm Electro-
experience in both HPS pacing and general electrophysiology; physiol. 2019;12:e007052.
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