[ICD electrode implantation for left bundle branch area pacing].

We are entering a new era of physiological pacing with left bundle branch area pacing (LBBAP), which is becoming an increasingly common in clinical routine. LBBAP has clear advantages over right ventricular (RV) and biventricular (BVP) pacing. Another option is to combine LBBAP and BVP, known as left bundle branch optimized (LOT) cardiac resynchronization therapy (CRT), which shortens the QRS duration more effectively than LBBAP and BVP alone. Implanting LOT CRT in patients with an ICD indication is particularly complicated. In this case, four leads are generally required. Additionally, the ICD device must have DF1/IS1 ports. Placing the ICD lead in the LBBAP position helps to eliminate the aforementioned problem and enables LOT CRTD to be performed with three leads. Furthermore, with an optimally stimulated QRS complex, CRTD therapy can be performed using two leads and a dual-chamber ICD device. With a VDD ICD lead, this therapy can be performed using just one lead and a VVI ICD device. To date, only a few publications have appeared on the implantation of ICD leads in the LBBAP position. Experience with the permanent implantation of standard ICD leads in the LBBAP position showed high implantation success rates and acceptable procedure and fluoroscopy durations. Most cases showed optimal ECG findings, such as shortened QRS duration, V6‑R wave peak time (V6RWPT) and/or V6-V1 interpeak interval. Defibrillation testing was successful in all but one of the patients published to date. To further develop this promising therapy, we need sheaths that have been developed and tested for this purpose (made from new materials and with different curves), as well as leads with fixed helixes and true bipolar sensing (to avoid atrial oversensing). Ideally, the new leads should have a narrow diameter, and the coils should be short yet sufficiently dimensioned. A VDD variant could also be an interesting option. Current ICD devices also need to be modernized to include the possibility of unipolar stimulation. From a clinical perspective, we should observe more patients over a longer period of time and focus on critical points.