Conduction system pacing using a rotatable connector enabling continuous pacing during lumenless lead deployment: a case report

TL;DR

This case report describes a new method for conduction system pacing using a rotatable connector to improve pacing during implantation.

Contribution

The first reported use of a rotatable connector for lumenless lead deployment in conduction system pacing.

Findings

Continuous pacing and impedance monitoring were achieved during lumenless lead deployment.

CSP success criteria were met with a short procedure time of 50 minutes.

The new connector enabled real-time monitoring of current of injury and impedance.

Abstract

Conduction system pacing (CSP) is an alternative to right ventricular pacing, providing more physiological ventricular activation. Current guidelines recommend CSP for patients with an expected ventricular pacing burden >20% and mildly reduced left ventricular ejection fraction. However, consistent conduction capture is not always achieved, with success rates of around 80% in the MELOS trial. Lumenless leads (LL) are widely used for CSP, but sustained, real-time pacing and impedance monitoring could enhance procedural control and decrease procedure time. The integration of a tool to overcome this limitation was highlighted as a future development in the 2025 EHRA CSP consensus. We report the first case using this approach.

An 80-year-old man with paroxysmal complete atrioventricular block and mildly reduced ejection fraction underwent pacemaker implantation. CSP was selected as the pacing strategy according to current recommendations. A Medtronic® 3830 LL was delivered via a C315His sheath, connected to a Micropace® Onestim-CRM stimulator through the new rotator connector 5944RL. This configuration allowed simultaneous septal penetration and continuous pacing for real-time monitoring of current of injury and continuous impedance analysis. CSP success criteria were achieved—left ventricular activation time 62 ms, broad R′ in V1, ventricular pacing thresholds for CSP 1.3 V @ 0.4 ms, fluoroscopy time 4:19 min, and shorter overall procedure (skin to skin, 50 min).

To our knowledge, this case represents the first reported use of a rotatable connector for CSP lumenless lead deployment, demonstrating the feasibility of continuous pacing with LLs for CSP. Further experience is needed to confirm long-term performance and clinical impact.

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