Conduction-guided intervention: A first-in-human study of computed tomography angiography-guided targeting of proximal conduction system structures.

Autores de IIS La Fe

• Óscar Cano Pérez

  Autor

• Joaquín Osca Asensi

  Autor

Participantes ajenos a IIS La Fe

• Tretter JT
• Asyraf T
• Spaziani S
• Zaretsky L
• Maceira AM
• Ben-Haim S

Grupos

• Grupo de Investigación Clínica y Traslacional en Cardiología

Abstract

BACKGROUND: Conduction system pacing (CSP) remains technically challenging because intentional targeting of proximal conduction structures, such as the distal His bundle and proximal left bundle branch (LBB) trunk, is difficult using current implantation techniques. OBJECTIVE: We evaluated a novel computed tomography angiography (CTA)-guided workflow designed to facilitate patient-specific targeting of these structures. METHODS: Conduction-guided intervention (CGI) integrates preprocedural cardiac CTA with patient-specific conduction system reconstruction and real-time fluoroscopic overlay. In this first-in-human prospective study, 40 consecutive patients undergoing CSP were enrolled. Procedural success was defined as implantation at a proximal conduction system target according to predefined anatomical and electrophysiological criteria. Clinical success required proximal conduction system capture with QRS correction at working output. RESULTS: Procedural success was achieved in 38/40 patients (95%). CTA analysis demonstrated substantial inter-individual variability in proximal conduction system anatomy, with marked differences in distances and trajectories along the AVN-His axis between patients. Distal His pacing according to predefined procedural criteria was initially achieved in 26 patients (65%). However, transition to proximal LBB trunk pacing was required in 12 patients because of inadequate QRS correction and/or unfavorable pacing thresholds. Final adjudicated pacing sites included distal His pacing in 14 patients (35%) and proximal LBB trunk pacing in 22 patients (55%), resulting in proximal conduction system pacing in 36/40 patients (clinical success 90%). CONCLUSION: CTA-guided conduction system mapping was feasible and enabled intentional targeting of proximal conduction structures in most patients. Integration of patient-specific anatomical information may complement conventional fluoroscopic and electrophysiological guidance during CSP implantation.

Copyright © 2026 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.

Keywords

• Cardiac computed tomography angiography; Conduction system pacing; His bundle pacing; Image-guided intervention; Left bundle branch pacing; Proximal conduction system pacing