In the early days of His bundle pacing (HBP) there was a issue of whether or not a backup lead should also be implanted.This controversy has apparently not been completely resolved and may have regained some steam as reports have appeared indicating that some not insignificant number of His leads develop high thresholds over time even though the initial threshold was appropriate.
Yand Ye et al (1) describe an interesting variation of using a backup in conjunction with a His Lead.They studied 16 AF patients who were pacemaker dependent in whom they attempted to place both a His lead and a left bundle branch area lead.(LBBA).The His lead was the primary pacing lead and the LBBA lead was considered the backup lead. Thirteen of the sixteen were successfully implanted. Although the results section of the paper is somewhat unclear apparently at least one patient had a increase in the capture threshold leading to switching to the LBBA lead. During the six month follow-up there were no lead dislodgments or ventricular perforations.There have been a few reports of late perforations of the LBBA pacing lead.
The authors conclude that the technique is doable and safe and may offer an approach at least for PM dependent patients with AF.In this group of patients the rivalry between HBP and LBBA pacing could be avoided.Maybe not a either or but a both.
1) Yand Ye, Feasibility and safety of both His Bundle Pacing and left bundle branch area pacing in atrial fibrillation patients: intermediate term follow-up.Journal of interventional cardiac electrophysiology. 2021 March 15 33723691