Left Bundle Branch Area Pacing (LBBAP) when you already have a single‑chamber leadless pacemaker

Educational overview to support a conversation with your electrophysiologist.

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Q: How to perform the procedure of Left Bundle Branch Area Pacing (LBBAP) in a patient with a unicameral leadless pacemaker (LP)?

Short answer: LBBAP is typically delivered with a transvenous pacing lead placed into the ventricular septum to engage the left bundle area. For someone who already has a single‑chamber LP, the usual pathways are to (1) add a transvenous LBBAP system and program the LP as backup or off, or (2) if it’s an Aveir™ LP and the team judges it appropriate, retrieve the LP and then implant an LBBAP system. A totally leadless LBBAP approach is investigational and not standard care. Discuss the specifics with your electrophysiologist (EP); what follows is an educational overview, not procedural instructions.

Important: This page is for general education only and does not provide step‑by‑step surgical instructions or medical advice. Decisions and programming must be individualized by your EP team.

1) Pre‑procedure assessment

  • Identify device make/model of the LP (e.g., Aveir™ VR vs Micra™) and confirm current dependency, thresholds, and battery status.
  • Review rhythm indication (e.g., high‑grade AV block, sinus‑node dysfunction, pacing‑induced dyssynchrony) and whether atrial sensing/pacing is needed.
  • Assess venous access (axillary/cephalic/subclavian), anticoagulation, infection risk, and imaging (echo) to plan septal trajectory.

2) Strategy options when an LP is already implanted

  • Keep LP in place; add transvenous LBBAP. Most common. Program the LP to a low backup rate or turn it OOO/monitor mode per device capability so it doesn’t compete with the new LBBAP system. Optimize sensing and blanking to avoid device–device interactions.
  • Retrieve Aveir™ and implant LBBAP. If the existing LP is Aveir™ and the team deems retrieval appropriate, dedicated retrieval catheters and protocols exist. Retrieval feasibility depends on device type, implant duration, tissue overgrowth, and operator experience.
  • Leave LP deactivated. In some cases the LP can be permanently programmed off and left in situ after LBBAP implantation.
  • Investigational: totally leadless LBBAP. Early case reports/series have achieved left‑septal (LBBAP‑like) capture using a leadless LV endocardial system (e.g., WiSE‑CRT) together with a leadless RV device. This is not routine clinical practice and may be limited to trials at specialized centers.

3) High‑level steps for adding a transvenous LBBAP system (educational)

  1. Venous access (typically axillary/cephalic). Introduce a delivery sheath designed for conduction‑system pacing.
  2. Targeting the septum. Map near the His region, then move ~1–1.5 cm toward the RV apex/inferiorly to the left bundle area. Advance the lead into the septum to obtain left bundle capture physiology.
  3. Confirm capture using ECG criteria (short stimulus‑to‑LV activation/QRS morphology consistent with LBB capture) and a robust safety margin at reasonable output/pulse width.
  4. Finalize device selection (single‑ vs dual‑chamber can) based on atrial needs, then proceed to closure.

Note: The exact tools, depths, and ECG criteria are determined by your EP team following contemporary guidelines and lab protocols.

4) Programming & interaction with the existing LP

  • Avoid device–device competition. Consider programming the LP to a lower backup rate or off. Coordinate sensing/blanking and rate‑response features to prevent inhibition or crosstalk.
  • Minimize interference. If two devices are present, certain sensors (e.g., minute ventilation) or high sensitivity settings on the transvenous system may need adjustment. Interrogation may require specific wand positioning.
  • Follow‑up. Verify stable thresholds, QRS morphology, and battery impact; set remote monitoring per center policy.

5) Risks and trade‑offs to discuss with your EP

  • Standard risks of transvenous lead placement (pneumothorax, lead dislodgement, perforation), plus rare LP retrieval risks if attempted.
  • Potential for device–device interaction if both systems remain active; careful programming usually mitigates this.
  • Benefits of LBBAP include more physiologic activation than RV apical pacing and may reduce pacing‑induced dyssynchrony in appropriate patients.

6) Questions to bring to your EP visit

  • Is my current LP retrievable or better left in place? If retrievable, what are the center’s success rates?
  • Will I benefit from atrial sensing/pacing (single‑ vs dual‑chamber system) together with LBBAP?
  • How will you program the LP and the new system to avoid competition and ensure best hemodynamics?

References (selected)

  1. 2023 HRS/APHRS/LAHRS Guideline on Cardiac Physiologic Pacing (CPP) — overview & recommendations for CSP/LBBAP. Heart Rhythm (2023).
  2. Abbott AVEIR™ Manuals & Retrieval Catheter IFU. Abbott HCP Site; FDA IFU PDF. Long‑term retrieval experience summarized on the product page.
  3. Case reports/series on combining leadless pacing with LBBAP or interactions. Frontiers in Cardiovascular Medicine (2024); HeartRhythm Case Rep (2023); J Cardiovasc Electrophysiol (2025).
  4. Interference/programming considerations. EHRA consensus (2022); interrogation nuance with other devices HeartRhythm Case Rep (2022).
  5. Investigational totally leadless LBBAP via LV endocardial systems. HeartRhythm Case Rep (2025).