A novel ECG‐based algorithm to determine right ventricular lead placement in permanent pacemaker patients (RVpace study)

Abstract

Introduction Fluoroscopy guidance alone is not sufficient for the accurate localization of the pacing lead (PL) in the right ventricle (RV) during implantation of the cardiac implantable electronic device (CIED). The aim of this study was to create a surface electrocardiogram (ECG) algorithm based on paced QRS (pQRS) morphology to accurately localize PL position in the RV. Methods and Results Thirty consecutive patients scheduled for catheter ablation of right heart arrhythmias were enrolled. After the elimination of index arrhythmia pacing from the RV interventricular septum (IVS), apex and free wall was performed and pQRS were recorded. The pacing site was verified both by fluoroscopy and transthoracic echocardiography. After a careful analysis of pQRS, a stepwise algorithm was developed to aid the proper positioning of the PL in RV. The algorithm was later prospectively validated in 31 pacemaker patients undergoing an elective generator exchange. A clear R wave in I, II, and V5 leads indicated proximal IVS. For a reliable indication of other RV sites, four ECG leads were crucial I, II, V5, and V6. A prospective evaluation of the algorithm revealed 90.3% agreement between RV lead localization obtained by ECG and echocardiography, with sensitivity of 92.5% (95% confidence interval [CI], 83.2%‐100.0%) and a positive predictive value of 96.0% (95% CI, 89.0%‐100.0%) for desired lead locations in RV. Conclusion A simple ECG algorithm can reliably differentiate between the sites of permanent PL implantation in the RV in CIED recipients.