Rare complications of left bundle branch area pacing: A systematic review of case-based evidence.

BACKGROUND

Left bundle branch area pacing (LBBAP) is increasingly being used as a physiological pacing strategy. However, the need for deep septal lead implantation exposes patients to a distinct set of uncommon complications.

OBJECTIVE

To systematically review case reports and case-based studies describing rare complications related to LBBAP.

METHODS

This review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020. PubMed, Scopus, and Google Scholar were searched for case reports and small case series that describe LBBAP-related complications. Given the heterogeneity of the data, a narrative synthesis was performed.

RESULTS

A total of 67 reports were included. Complications were grouped into 5 categories: septal injury, vascular injury, valvular/subvalvular damage, mechanical or lead-related complications, and electrophysiological disturbances. Septal injury was the most frequently reported complication, ranging from intraseptal hematoma to delayed perforation presenting with arrhythmias, thromboembolism, or tamponade. Vascular complications included coronary and venous injuries, sometimes mimicking acute coronary syndromes. Valvular and mechanical complications occurred despite normal electrical parameters. Electrophysiological complications included ventricular arrhythmias, pacing-induced cardiomyopathy, and T-wave oversensing. Management varied according to the clinical presentation, from conservative observation to lead revision or interventional treatment.

CONCLUSION

Rare complications of LBBAP reflect the transseptal nature of the procedure and can be grouped into 5 clinical phenotypes. Recognition requires the integration of symptoms, device data, and imaging. Normal device parameters do not exclude clinically relevant structural complications. A phenotype-based approach may help to guide diagnosis and management in clinical practice.