Chair Suneet Mittal (New York, US) led a session on conduction system pacing, featuring Case Operator Apoor Patel (Houston Methodist, Houston, US) and panellists Syeda Atiqa Batul (Wilkes-Barre, US) and Valentina Kutyifa (Rochester, US). Dr Patel presented a case of an 85-year-old male with prior CABG, atrial fibrillation, and heart block, undergoing left bundle branch pacing with the Boston Scientific system. He detailed contrast injection for tricuspid valve visualisation, lead rotation techniques, and sheath selection. Despite multiple adjustments, full left bundle capture was not achieved, highlighting real-world challenges in conduction system pacing.

The panel discussed troubleshooting strategies, including fixation beats, impedance monitoring, and sheath optimisation. They emphasised careful follow-up to detect pacing-induced cardiomyopathy, particularly when only septal capture is achieved. Dr Patel considered adding an LV lead but opted against it due to the patient’s condition. The discussion covered fluoroscopy versus contrast injection for lead placement. The session concluded with insights into procedural efficiency, safety, and long-term outcomes, reinforcing the complexity of achieving reliable conduction system pacing.