His bundle pacing: troubleshooting at implantation

His bundle pacing produces electrocardiograms (ECGs) that give the impression that it is physiological like no other form of cardiac pacing requiring ventricular stimulation. Several special features of the implantation technique of a His bundle lead that distinguish it significantly from the implantation of other endocardial leads need to be considered. This overview provides a number of practical “hands-on” tips and tricks, from implantation set-up (12-lead ECG, no electrophysiology unit, no His bundle catheter), venous access, handling of delivery catheters and leads, interpretation of intracardiac electrograms, fluoroscopy and the surface ECG, finding the optimal pacing site, and implantation of the lead to fine-tuning and troubleshooting of difficult implantations and lead dislodgement. This review should help to facilitate the implantation of His bundle leads, shorten the learning curve and help to improve implantation results.