Right-Sided Left Bundle Branch Area Pacing in a Patient With Severe Scoliosis
A 32-year-old patient with complete atrioventricular (AV) block, progressive muscular dystrophy, and severe scoliosis presented a challenge for permanent pacemaker implantation. He could not lie supine and could only tolerate a left lateral position with his neck elevated. His spinal deformity had also altered the usual relationship between the chest, heart, and venous structures.
The cardiac pacing team at Renji Hospital, Shanghai Jiao Tong University School of Medicine, developed an individualized plan: right-sided left bundle branch area pacing (LBBAP) through the right axillary vein.
## A need for permanent pacing
The patient sought care after experiencing recurrent chest tightness and dizziness. Electrocardiography showed complete AV block, with a heart rate of approximately 30–40 beats per minute. Permanent pacing was needed to address the symptomatic bradycardia.
Device selection required consideration of more than the immediate heart rate. As a young patient with complete AV block, he was expected to require a substantial amount of ventricular pacing over many years. Progressive muscular dystrophy can also be associated with cardiac involvement, although its manifestations vary by disease subtype.
The team therefore selected LBBAP, a form of conduction system pacing intended to provide a more physiological pattern of ventricular activation than conventional right ventricular pacing.
## Why the usual left-sided approach was unsuitable
Pacemakers are commonly implanted from the left side of the chest. In this case, the patient's required left lateral position made conventional left-sided venous access and device manipulation difficult.
There was also a practical long-term concern: the patient used a walking aid that placed pressure on his left anterior chest. A generator implanted in that location could be exposed to repeated compression, potentially increasing the risk of discomfort and pocket or skin complications.
The team chose a right axillary venous approach to accommodate both the procedural constraints and the patient's daily activities.
## Adapting the procedure to altered anatomy
A right-sided approach to LBBAP presents different angles for advancing the delivery system and positioning the ventricular lead against the interventricular septum. In this patient, severe scoliosis added another layer of difficulty by altering thoracic anatomy, cardiac orientation, and the venous course.
After obtaining right axillary venous access, the team reshaped the delivery sheath to suit the patient's anatomy. Under electrophysiological guidance, the ventricular lead was advanced to the left bundle branch area. A paced QRS duration of 81 milliseconds was reported after lead positioning.
An atrial lead was subsequently implanted in the interatrial septum. The reported atrial and ventricular pacing parameters were satisfactory.
## Outcome and clinical perspective
The procedure took approximately 1.5 hours. Following implantation, the patient's heart rate increased to approximately 60 beats per minute. His chest tightness and dizziness improved significantly, and he was later discharged.
This case illustrates that complex pacemaker implantation is not solely a question of reaching the target site. Pacing strategy, patient positioning, venous access, delivery-system configuration, generator location, and anticipated long-term needs may all influence the plan.
The immediate procedural and clinical results were encouraging. As with any individual case, however, longer-term follow-up is needed to assess lead performance, pocket integrity, and cardiac function.