Septal Artery Injury During Left Bundle Branch Area Pacing: Electrophysiological Warning and Coil Embolization.

BACKGROUND

Left bundle branch area pacing (LBBAP) requires deep septal lead implantation and carries a risk of septal vascular injury.

CASE SUMMARY: A 58-year-old man with binodal disease underwent dual-chamber pacemaker implantation using LBBAP. Initial high septal lead placement was associated with markedly elevated impedance and suboptimal pacing parameters. After repositioning, parameters normalized. However, the patient developed acute chest pain, ST-segment elevation, and ventricular tachycardia. Coronary angiography demonstrated septal branch perforation with contrast extravasation, and echocardiography confirmed an interventricular septal hematoma. Transcatheter coil embolization achieved complete hemostasis with favorable recovery.

DISCUSSION: Abnormal pacing parameters and ventricular arrhythmias may represent early electrophysiological markers of septal vascular injury during LBBAP, providing important insights into its recognition, management, and procedural implications.

TAKE-HOME MESSAGES: Septal branch injury is a rare but potentially serious complication of LBBAP. Early recognition and prompt imaging-guided intervention are essential to ensure procedural safety.