Computational analysis of intracardiac collision risk and optimal site for right ventricular leadless left bundle branch area pacing: a simulation study
File(s)
Published version
Author(s)
Type
Journal Article
Abstract
Background
Conduction system pacing with leadless left bundle branch area pacing (LBBAP) is a promising application of leadless pacemakers (L-PMs). However, the mechanical impact of the L-PM on intracardiac structures may worsen tricuspid regurgitation and induce ventricular arrhythmia. The optimal site of leadless conduction system pacing also remains unclear.
Objective
This study aimed to quantify device- and site-specific collision risks and identify the optimal site for leadless LBBAP using computational modeling.
Methods
We conducted a modeling study assessing collision risks of contemporary (Micra TPS, Aveir AR, and Aveir VR) and future L-PM devices and exploring the optimal site for leadless LBBAP using cardiac computed tomography models from 10 patients with heart failure. Virtual L-PM implantation on the right ventricular (RV) septal wall was performed, and models of the RV free wall, papillary muscles, moderator band, and tricuspid valve structures enabled assessment of device–structure interactions. Computer simulations examined collision risk across devices of varying dimensions throughout the cardiac cycle.
Results
Collision risk increased with device length and volume, primarily driven by RV wall interactions. Apical pacing sites carried a 73.6%–75.2% collision risk, and overall wall collisions increased by 3%–8% per 5 mm device length. Tricuspid valve and papillary muscle collisions depended on implant region, with the highest risks of collision in basal-inferoseptal (>70%) and mid-inferoseptal regions (>40%), respectively. Leadless LBBAP via the left anterior fascicle had the lowest collision rates.
Conclusion
These findings support patient-specific device selection and careful septal targeting of leadless LBBAP to minimize complications, optimize physiological activation, and guide future L-PM designs.
Conduction system pacing with leadless left bundle branch area pacing (LBBAP) is a promising application of leadless pacemakers (L-PMs). However, the mechanical impact of the L-PM on intracardiac structures may worsen tricuspid regurgitation and induce ventricular arrhythmia. The optimal site of leadless conduction system pacing also remains unclear.
Objective
This study aimed to quantify device- and site-specific collision risks and identify the optimal site for leadless LBBAP using computational modeling.
Methods
We conducted a modeling study assessing collision risks of contemporary (Micra TPS, Aveir AR, and Aveir VR) and future L-PM devices and exploring the optimal site for leadless LBBAP using cardiac computed tomography models from 10 patients with heart failure. Virtual L-PM implantation on the right ventricular (RV) septal wall was performed, and models of the RV free wall, papillary muscles, moderator band, and tricuspid valve structures enabled assessment of device–structure interactions. Computer simulations examined collision risk across devices of varying dimensions throughout the cardiac cycle.
Results
Collision risk increased with device length and volume, primarily driven by RV wall interactions. Apical pacing sites carried a 73.6%–75.2% collision risk, and overall wall collisions increased by 3%–8% per 5 mm device length. Tricuspid valve and papillary muscle collisions depended on implant region, with the highest risks of collision in basal-inferoseptal (>70%) and mid-inferoseptal regions (>40%), respectively. Leadless LBBAP via the left anterior fascicle had the lowest collision rates.
Conclusion
These findings support patient-specific device selection and careful septal targeting of leadless LBBAP to minimize complications, optimize physiological activation, and guide future L-PM designs.
Date Issued
2026-05-01
Date Acceptance
2026-03-04
Citation
Heart Rhythm O2, 2026, 7 (5), pp.947-958
ISSN
2666-5018
Publisher
Elsevier
Start Page
947
End Page
958
Journal / Book Title
Heart Rhythm O2
Volume
7
Issue
5
Copyright Statement
© 2026 Heart Rhythm Society. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
License URL
Identifier
10.1016/j.hroo.2026.02.030
Subjects
Heart digital twins
CSP
conduction system pacing
Right ventricular pacing
Leadless pacemaker
LBBAP
Left bundle branch area pacing
Publication Status
Published
Date Publish Online
2026-03-13