{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T09:51:15Z","timestamp":1791453075297,"version":"4.3.3"},"reference-count":30,"publisher":"MDPI AG","issue":"19","license":[{"start":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T00:00:00Z","timestamp":1790640000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T00:00:00Z","timestamp":1790640000000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>Background: Transthoracic echocardiography (TTE)-assisted left bundle branch area pacing (LBBAP) is a potential supplementary to fluoroscopy-guided implantation and may reduce radiation. Objectives: To evaluate the feasibility and long-term stability of TTE-assisted, low-fluoroscopy LBBAP across different workflows and lead types. Methods: This retrospective study enrolled 45 consecutive patients between November 2021 and June 2022, analyzing 42 successful cases. Patients were stratified by workflow approach (non-scrubbed, n = 24; scrubbed aseptic, n = 18) and lead type (lumen-less leads [LLLs], n = 20; stylet-driven leads [SDLs], n = 22). Procedural and pacing parameters were assessed through a 4-year follow-up. Results: In select patients with adequate acoustic windows, multi-stage TTE-assisted LBBAP remained feasible despite a 54.8% overweight\/obesity rate. The scrubbed aseptic workflow showed significantly shorter procedural and fluoroscopy times (p &lt; 0.01), though confounded by the learning curve. Beyond 6 months, pacing parameters remained stable and comparable between workflows through 4 years. Regarding lead types, procedural durations were similar. However, the SDL group exhibited significantly higher pacing thresholds at implant and 6 months (p &lt; 0.05) and maintained a higher numerical trend through Year 4, though both lead types demonstrated stable chronic sensing and impedance profiles. No late dislodgements, device-related infections, or late complications occurred across available patient-years. Conclusions: TTE-assisted LBBAP is a clinically feasible approach that can supplement conventional implantation in selected patients with favorable acoustic windows. While achieving excellent 4-year functional durability, procedural improvements reflect the combined effect of workflow refinement and operator proficiency.<\/jats:p>","DOI":"10.3390\/diagnostics16193172","type":"journal-article","created":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T16:33:12Z","timestamp":1790699592000},"page":"3172","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Transthoracic Echocardiography-Assisted, Low-Fluoroscopy Left Bundle Branch Area Pacing: A Comparison of Implantation Approaches and Lead Types"],"prefix":"10.3390","volume":"16","author":[{"given":"Po-Hua","family":"Chu","sequence":"first","affiliation":[{"name":"Cardiovascular Division, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104217, Taiwan"},{"name":"Department of Nursing, MacKay Junior College of Medicine, Nursing, and Management, New Taipei City 252005, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"writing-original-draft","vocabulary":"credit"},{"role":"data-curation","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2858-3493","authenticated-orcid":false,"given":"Chung-Lieh","family":"Hung","sequence":"additional","affiliation":[{"name":"Cardiovascular Division, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104217, Taiwan"},{"name":"Institute of Biomedical Sciences, MacKay Medical University, New Taipei City 252005, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7032-9731","authenticated-orcid":false,"given":"Kuo-Tzu","family":"Sung","sequence":"additional","affiliation":[{"name":"Cardiovascular Division, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104217, Taiwan"},{"name":"Department of Medicine, MacKay Medical University, New Taipei City 252005, Taiwan"},{"name":"Department of Telehealth, MacKay Memorial Hospital, Taipei 104217, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"visualization","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2699-9230","authenticated-orcid":false,"given":"Shu-Fen","family":"Hsu","sequence":"additional","affiliation":[{"name":"Department of Telehealth, MacKay Memorial Hospital, Taipei 104217, Taiwan"},{"name":"School of Nursing, MacKay Medical University, Taipei 252005, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"visualization","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"}]},{"given":"Cheng-Ting","family":"Tsai","sequence":"additional","affiliation":[{"name":"Cardiovascular Division, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104217, Taiwan"},{"name":"Department of Nursing, MacKay Junior College of Medicine, Nursing, and Management, New Taipei City 252005, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"}]},{"given":"Jen-Yuan","family":"Kuo","sequence":"additional","affiliation":[{"name":"Cardiovascular Division, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104217, Taiwan"},{"name":"Department of Nursing, MacKay Junior College of Medicine, Nursing, and Management, New Taipei City 252005, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sheng-Hsiung","family":"Chang","sequence":"additional","affiliation":[{"name":"Cardiovascular Division, Department of Internal Medicine, MacKay Memorial Hospital, Taipei 104217, Taiwan"},{"name":"Department of Nursing, MacKay Junior College of Medicine, Nursing, and Management, New Taipei City 252005, Taiwan"}],"role":[{"vocabulary":"crossref","role":"author"},{"role":"conceptualization","vocabulary":"credit"},{"role":"methodology","vocabulary":"credit"},{"role":"writing-review-editing","vocabulary":"credit"},{"role":"supervision","vocabulary":"credit"},{"role":"resources","vocabulary":"credit"},{"role":"validation","vocabulary":"credit"},{"role":"investigation","vocabulary":"credit"}]}],"member":"1968","published-online":{"date-parts":[[2026,9,29]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1365","DOI":"10.1111\/pace.14296","article-title":"Feasibility study for echocardiography-guided lead insertion for permanent cardiac implantable electronic devices","volume":"44","author":"Sogade","year":"2021","journal-title":"Pacing Clin. Electrophysiol."},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Liu, P., Wang, Q., Sun, H., Qin, X., and Zheng, Q. (2021). Left bundle branch pacing: Current knowledge and future prospects. Front. Cardiovasc. Med., 8.","DOI":"10.3389\/fcvm.2021.630399"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"735","DOI":"10.1016\/j.hrthm.2024.08.052","article-title":"Conduction system pacing associated with reduced heart failure hospitalizations and all-cause mortality compared with traditional right ventricular pacing in the Medicare population","volume":"22","author":"Vijayaraman","year":"2025","journal-title":"Heart Rhythm"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1791","DOI":"10.1016\/j.hrthm.2019.06.016","article-title":"A beginner\u2019s guide to permanent left bundle branch pacing","volume":"16","author":"Huang","year":"2019","journal-title":"Heart Rhythm"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1619","DOI":"10.1016\/j.hrthm.2014.05.040","article-title":"Incidence and predictors of right ventricular pacing-induced cardiomyopathy","volume":"11","author":"Khurshid","year":"2014","journal-title":"Heart Rhythm"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"e009261","DOI":"10.1161\/CIRCEP.120.009261","article-title":"Long-term safety and feasibility of left bundle branch pacing in a large single-center study","volume":"14","author":"Su","year":"2021","journal-title":"Circ. Arrhythm. Electrophysiol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"14","DOI":"10.1016\/j.apradiso.2017.08.010","article-title":"Patient exposure during fluoroscopy-guided pacemaker implantation procedures","volume":"138","author":"Alkhorayef","year":"2018","journal-title":"Appl. Radiat. Isot."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"af784.575","DOI":"10.1093\/eurheartj\/ehaf784.575","article-title":"Radiation exposure and procedure duration in left ventricular area pacing versus right ventricular pacing: A single-center study","volume":"46","author":"Lehmonen","year":"2025","journal-title":"Eur. Heart J."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Wang, Z., Zhu, H., Li, X., Yao, Y., Liu, Z., and Fan, X. (2021). Comparison of procedure and fluoroscopy time between left bundle branch area pacing and right ventricular pacing for bradycardia: The learning curve for the novel pacing strategy. Front. Cardiovasc. Med., 8.","DOI":"10.3389\/fcvm.2021.695531"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1111\/pace.13842","article-title":"Radiation exposure during cardiac device implantation: Lessons learned from a multicenter registry","volume":"43","author":"Bru","year":"2020","journal-title":"Pacing Clin. Electrophysiol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"542","DOI":"10.1016\/j.hrcr.2017.09.003","article-title":"Implantation of a dual-chamber permanent pacemaker in a pregnant patient guided by intracardiac echocardiography and electroanatomic mapping","volume":"3","author":"Chua","year":"2017","journal-title":"HeartRhythm Case Rep."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1002\/jcu.22830","article-title":"Transthoracic echocardiography-guided left bundle branch pacing without fluoroscopic guidance: A case report","volume":"49","author":"Tan","year":"2021","journal-title":"J. Clin. Ultrasound"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"242","DOI":"10.2459\/JCM.0b013e32834eecbf","article-title":"Echocardiography-guided versus fluoroscopy-guided temporary pacing in the emergency setting: An observational study","volume":"14","author":"Pinneri","year":"2013","journal-title":"J. Cardiovasc. Med."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"2525","DOI":"10.1111\/jce.14205","article-title":"Intracardiac echocardiography-guided left bundle branch pacing in a patient with tricuspid valve replacement","volume":"30","author":"Vijayaraman","year":"2019","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e011408","DOI":"10.1161\/CIRCEP.122.011408","article-title":"Intracardiac echocardiography-guided implantation for proximal left bundle branch pacing","volume":"16","author":"Kuang","year":"2023","journal-title":"Circ. Arrhythmia Electrophysiol."},{"key":"ref_16","first-page":"125","article-title":"Emergent transvenous cardiac pacing using ultrasound guidance: A prospective study versus the standard fluoroscopy-guided procedure","volume":"5","author":"Ferri","year":"2016","journal-title":"Eur. Heart J. Acute Cardiovasc. Care"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"324","DOI":"10.1016\/j.hroo.2025.11.027","article-title":"Echocardiographic assessment after left bundle branch area pacing: Impact on the tricuspid valve apparatus, clinical value, and perspectives","volume":"7","author":"Barre","year":"2026","journal-title":"Heart Rhythm O2"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"e746","DOI":"10.1016\/j.hrthm.2024.12.039","article-title":"Intraprocedural transthoracic echocardiography to facilitate left bundle branch pacing: EC-LBBP","volume":"22","author":"Vijayaraman","year":"2025","journal-title":"Heart Rhythm"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"875","DOI":"10.1111\/jce.16212","article-title":"Comparison of clinical outcomes between transthoracic echocardiography-and X-ray-guided left bundle branch pacing for bradycardia: A randomized controlled trial","volume":"35","author":"Yang","year":"2024","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"2242","DOI":"10.1016\/j.hrthm.2024.05.007","article-title":"Left bundle branch area pacing using a stylet-driven, retractable-helix lead: Short-term results from a prospective multicenter IDE trial (the BIO-CONDUCT study)","volume":"21","author":"Liu","year":"2024","journal-title":"Heart Rhythm"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1540","DOI":"10.1111\/jce.15558","article-title":"Initial experience of left bundle branch area pacing using stylet-driven pacing leads: A multicenter study","volume":"33","author":"Ozpak","year":"2022","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"439","DOI":"10.1111\/jce.14851","article-title":"Left bundle branch area pacing using stylet-driven pacing leads with a new delivery sheath: A comparison with lumen-less leads","volume":"32","author":"Calle","year":"2021","journal-title":"J. Cardiovasc. Electrophysiol."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Byeon, K., Kim, H.R., Park, S.J., Park, Y.J., Choi, J.H., Kim, J.Y., Park, K.M., On, Y.K., and Kim, J.S. (2022). Initial experience with left bundle branch area pacing with conventional stylet-driven extendable screw-in leads and new pre-shaped delivery sheaths. J. Clin. Med., 11.","DOI":"10.3390\/jcm11092483"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1208","DOI":"10.1093\/europace\/euad043","article-title":"EHRA clinical consensus statement on conduction system pacing implantation: Endorsed by the Asia Pacific Heart Rhythm Society (APHRS), Canadian Heart Rhythm Society (CHRS), and Latin American Heart Rhythm Society (LAHRS)","volume":"25","author":"Burri","year":"2023","journal-title":"Europace"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"e13","DOI":"10.15420\/cfr.2021.04","article-title":"How to Implant His Bundle and Left Bundle Pacing Leads: Tips and Pearls","volume":"7","author":"Ponnusamy","year":"2021","journal-title":"Card. Fail. Rev."},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Tudorancea, I., Haba, M.\u0218.C., Placinta, M.C., Popa, I.P., Calistrat, E.G., Guila, A., Cri\u0219u, D., Onofrei, V., \u0218erban, D.N., and \u0218erban, I.L. (2026). CUSUM analysis as a predictive tool for the learning curve in left bundle branch area pacing. J. Clin. Med., 15.","DOI":"10.3390\/jcm15010335"},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Yu, G.I., Kim, T.H., Lee, J.M., Kim, D., Yu, H.T., Uhm, J.S., Joung, B., Pak, H.N., and Lee, M.H. (2024). Predictors of success in left bundle branch area pacing with stylet-driven pacing leads: A multicenter investigation. Front. Cardiovasc. Med., 11.","DOI":"10.3389\/fcvm.2024.1449859"},{"key":"ref_28","first-page":"101171","article-title":"Conduction system pacing learning curve: Left bundle pacing compared to His bundle pacing","volume":"44","author":"Shi","year":"2023","journal-title":"Int. J. Cardiol. Heart Vasc."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Abdin, A., Burri, H., Imnadze, G., Turkmani, K., Al Ghorani, H., Almasri, A., Werner, C., and Kulenthiran, S. (2025). Outcomes of stylet-driven leads compared to lumenless leads for left bundle branch are pacing: Systematic review and meta-analysis. Clin. Res. Cardiol.","DOI":"10.1007\/s00392-025-02673-w"},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Chen, X., and Dong, J. (2024). Stylet-driven leads compared with lumenless leads for left bundle branch area pacing: A systematic review and meta-analysis. BMC Cardiovasc. Disord., 24.","DOI":"10.1186\/s12872-024-04273-4"}],"container-title":["Diagnostics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4418\/16\/19\/3172\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T09:06:57Z","timestamp":1791450417000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4418\/16\/19\/3172"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,29]]},"references-count":30,"journal-issue":{"issue":"19","published-online":{"date-parts":[[2026,10]]}},"alternative-id":["diagnostics16193172"],"URL":"https:\/\/doi.org\/10.3390\/diagnostics16193172","relation":{},"ISSN":["2075-4418"],"issn-type":[{"value":"2075-4418","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,29]]}}}