Abstract 

Physiological biventricular pacing is an attractive alternative to conventional right ventricular (RV) pacing in the management of conduction system disease. RV septal pacing is effective but dogged by lead instability and occasional serious tricuspid valve injury. Permanent His-bundle pacing has been achieved, but challenges remain, including high pacing threshold, low ventricular electrogram amplitude, lead instability, and procedural complexity.We recently described an alternative pacemaker lead trajectory to achieve physiological pacing, by lead implantation into the interventricular septum through the septal perforator branch of the great cardiac vein, the terminal branch of the coronary sinus. We first exploited this catheter trajectory to achieve transcatheter mitral cerclage annuloplasty, therefore we term our technique cerclage parahisian septal pacing. In our initial case description, we achieved physiological cerclage parahisian septal pacing with a low pacing threshold using a conventional bipolar coronary sinus pacing electrode. In this study, we evaluated cerclage parahisian septal pacing further in a prospective cohort series and introduced a new type of pacing lead.

Cerclage parahisian septal pacing is a feasible approach to achieve physiological pacing. Although available commercial pacing leads are ill-suited for cerclage pacing, this early human experience informed the development of a purpose-built prototype that is easy to implant. Cerclage pacing, using a dedicated catheter, should be investigated as an alternative to direct right-sided approaches to His-bundle pacing.​​