Sheath-Assisted Redo Left Bundle Branch Area Pacing Without Additional Venous Puncture.

BACKGROUND: Left bundle branch area pacing (LBBAP) requires delivery-sheath support for implantation and revision. Redo procedures for lead-related complications may require additional venous puncture to regain access. CASE SUMMARY: A 79-year-old man underwent LBBAP for complete atrioventricular block. Four days later, abrupt threshold elevation and loss of capture occurred. Fluoroscopy showed complete interventricular septal perforation with lead-tip migration into the left ventricular cavity. Lead revision was performed using a sheath-assisted access-preserving technique without additional venous puncture. A modified 4-F short sheath was advanced over the existing lead, allowing guidewire insertion, sheath upsizing, and successful LBBAP lead reimplantation. DISCUSSION: Delayed septal perforation is a rare but recognized LBBAP complication. This case demonstrates a simple technique using standard sheaths and guidewires that may reduce invasiveness during selected redo LBBAP procedures. TAKE-HOME MESSAGE: Sheath-assisted access preservation can facilitate LBBAP lead revision without additional venous puncture.