The significance of ST-segment elevation in the perioperative period of conduction system pacemaker implantation.

BACKGROUND

Conduction system pacing (CSP) is becoming the standard of care in cardiac electrotherapy. To achieve the best physiological effect, the pacing lead should penetrate deeply into the myocardium of the interventricular septum (IVS). While the beneficial effect of CSP on left ventricular function has been proven, the safety profile and late complications, including IVS perforation, local myocardial damage, and ST-segment changes, continue to be assessed.

AIMS: The aim of this study was to assess the prevalence, clinical significance, and potential mechanisms of ST-segment elevation (STE) following CSP implantation.

METHODS

We retrospectively analyzed 412 patients who underwent CSP between 2020 and 2024 in two cardiology departments.

RESULTS

Significant STE, consistent with STE myocardial infarction criteria, was recorded in five cases. In most patients, STE occurred several hours after the procedure, manifested in anterior leads (V1-V4), and was associated with anginal pain and significant troponin levels. Coronary angiography, performed in 4 cases, showed the possible mechanisms. These included damage to septal branches resulting in septal hematoma (2 cases), occlusion of the left anterior descending artery requiring percutaneous transluminal coronary angioplasty (1 case), and procedure-related stress inducing takotsubo syndrome (1 case).

CONCLUSIONS

Prolonged STE may occur several hours after the procedure, emphasizing the necessity of patient monitoring. STE is a critical marker that may signify iatrogenic acute coronary syndrome from direct damage to the left anterior descending artery or its septal branches, or the formation of IVS hematoma and fistulas. Multimodality diagnostic tools, such as urgent selective coronary angiography or computed tomography angiography, are mandatory to detect serious complications early and facilitate appropriate treatment.