Obstacles preventing biventricular pacing mitigated with lead extraction and His bundle pacing to achieve effective cardiac resynchronization

Introduction Cardiac resynchronization therapy (CRT) achieved by implanting a lead via the coronary sinus (CS) system significantly improves well-being, symptoms, morbidity, and mortality in appropriately selected populations with advanced heart failure (HF) or pacing-induced cardiomyopathy. Despite improvements in implant technique, lead design, and pacing algorithms, there still remains a significant nonresponder rate, high implant failure, and higher risk of complications. The options for CRT are generally limited to surgical lead placement if lead delivery via the CS is not feasible. His bundle pacing (HBP) engages and recruits the native His-Purkinje system distal to the level of block allowing for rapid and coordinated electromechanical ventricular activation avoiding dyssynchrony with hemodynamics and remodeling similar or superior to CRT via the CS. Despite the potential for superior CRT and less complex procedures, HBP is underutilized in cases where CRT via the CS is not feasible. We present a case with several obstacles to CRT that was ultimately achieved with HBP.