Transesophageal echocardiography versus fluoroscopy-guided left bundle branch area pacing: a comparative study

Conduction System Pacing (CSP), particularly Left Bundle Branch Area Pacing (LBBAP), has emerged as a physiological alternative to conventional ventricular pacing. However, optimal lead placement remains challenging. In this study, we investigated whether intraprocedural transesophageal echocardiography (TEE) can facilitate LBBAP implantation and improve procedural efficiency, lead positioning, and electrical outcomes compared with the conventional fluoroscopy-guided approach.

In this single-center, retrospective, non-randomized cohort study, we evaluated 405 consecutive patients undergoing LBBAP between January 2018 and March 2025. The study compared a conventional fluoroscopy-only approach in the initial 198 patients and a TEE-guided approach in the subsequent 207 patients. Primary endpoints were categorized as measures of procedural efficiency assessed by total procedure time and fluoroscopy time and electrical performance evaluated by post-procedural QRS duration, R-wave peak time in lead V6, and final lead impedance.

The TEE-guided group demonstrated significantly shorter total procedure and fluoroscopy times (65.5 ± 25.2 vs. 89.9 ± 37.9 min; p < 0.001/ 12.8 ± 9.9 vs. 15.8 ± 10.5 min; p < 0.001). Post-procedural QRS duration was narrower in the TEE group (108 ± 16 vs. 116 ± 15 ms; p < 0.001), with a more pronounced reduction in patients with baseline wide QRS (> 140 ms) (ΔQRS: −54 ± 23 vs. −46 ± 21 ms; p < 0.001). Notably, lead impedance was significantly lower with TEE guidance (523.6 ± 115.6 vs. 611.3 ± 155.9 Ω; p < 0.001), while pacing thresholds and R-wave amplitudes were similar. Complication rates were low and comparable.

TEE-guided LBBAP implantation is associated with enhanced procedural efficiency and adequate cardiac electrical resynchronization. Incorporation of TEE into CSP implantation protocols warrants further evaluation in randomized trials.

Transesophageal echocardiography versus fluoroscopy-guided left bundle branch pacing for pacemaker implant. Representative fluoroscopic and TEE images illustrate left bundle branch pacing with conventional fluoroscopy-only versus adjunctive TEE guidance. TEE allows direct visualization of the interventricular septum and electrode tip, facilitating accurate lead positioning. Quantitative comparisons demonstrate that TEE-guided implantation was associated with significantly shorter fluoroscopy time, comparable or reduced procedure duration, and improved electrical outcomes, including narrower QRS duration and shorter V6 R-wave peak time. RA = right atrium; RV = right ventricle; LA = left atrium; LV = left ventricle; MV = mitral valve; MS = membranous septum; IVS = interventricular septum; TEE = transesophageal echocardiography; LBBP = left bundle branch pacing; RWPT = R-wave peak time