Accuracy of Fluoroscopic and Electrocardiographic Criteria for Pacemaker Lead Implantation by Comparison with Three-Dimensional Echocardiography

Mărgulescu, Andrei D.; Suran, B.; Rimbaş, Roxana Cristina; Silişte, Cǎlin; Vinereanu, Dragoş

doi:10.1016/j.echo.2012.04.010

Cited by 25 publications

(42 citation statements)

References 27 publications

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“…The TZ in precordial leads was earlier in the septal group. In the study by Margulescu et al, 21 with lead position confirmed by TTE, the ECG criteria showed low accuracy in identifying RVOT septal locations. In our study, we found that paced QRS duration and negative or isoelectric QRS vector in lead I are independent predictors of true RVOT septal pacing.…”

Section: Discussionmentioning

confidence: 99%

Electrocardiographic predictors of validated right ventricular outflow tract septal pacing for correct localization of transthoracic echocardiography

Wei

Tang

Chen

et al. 2018

Clinical Cardiology

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BackgroundElectrocardiographic (ECG) characteristics of true right ventricular outflow tract (RVOT) septal pacing have not been clearly demonstrated.HypothesisWe hypothesized that ECG parameters would help operators differentiate true RVOT septum from non‐septal septum.MethodsWe analyzed 151 patients who underwent pacemaker implantation with a ventricular lead in the RVOT. Transthoracic echocardiographic (TTE) determination of pacing sites was applied in all patients after implantation. A 12‐lead ECG was recorded during forced ventricular pacing.ResultsAccording to TTE orientation, pacing at the RVOT septum was achieved in 94 patients (62.3%). Compared with nonseptal pacing, septal pacing had significantly shorter QRS duration (139.2 ± 18.5 ms vs 155.5 ± 14.7 ms; P < 0.001). More frequent negative or isoelectric QRS vector in lead I (76% vs 32%; P < 0.001), lead II/III R‐wave amplitude ratio < 1 (52% vs 25%; P = 0.001), and aVR/aVL QS‐wave amplitude ratio < 1 (59% vs 32%; P = 0.001) were observed in septal pacing. Transitional zone (TZ) score (3.8 ± 0.96 vs 4.2 ± 0.90; P = 0.004) and TZ index (0.3 ± 0.5 vs 0.6 ± 0.7; P = 0.008) were significantly lower in septal pacing than in nonseptal pacing, respectively. In multivariate analysis, paced QRS duration and negative or isoelectric QRS vector in lead I independently predicted RVOT septal pacing (P < 0.001). At ROC curve analysis, paced QRS duration ≤145 ms identified RVOT septal pacing with 85.1% sensitivity and 78.9% specificity.ConclusionsThis study reveals the heterogeneity of lead placement within the RVOT. Narrower paced QRS duration and negative or isoelectric QRS vector in lead I independently predict RVOT septal pacing.

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Section: Discussionmentioning

confidence: 99%

Electrocardiographic predictors of validated right ventricular outflow tract septal pacing for correct localization of transthoracic echocardiography

Wei

Tang

Chen

et al. 2018

Clinical Cardiology

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“…Most leads are positioned using standard posterior-anterior (PA) fluoroscopy. 10 Paced QRS morphology and standard QRS axis evaluation of lead position can also be utilized and may be particularly useful in determining an apical versus nonapical site of pacing, as well as a septal versus lateral position 11,12 (Fig. A standard PA view is not sufficient when targeting a standard pacing lead to the atrial septum, right ventricular outflow tract, or a specific region of the left ventricle.…”

Section: Imaging For Lead Placementmentioning

confidence: 99%

“…52 The expected impedance range for most leads range is 400 to 1200 ohms. Pacing Clin Electrophysiol 30 [12]: [1438][1439][1440][1441][1442][1443][1444]2007 insulation defects in the lead, or device header problems. 53 An elevated high-voltage lead impedance can also be due to the implantable cardioverter-defibrillator (ICD) not being within the pocket, because the ICD can is part of the circuit.…”

Section: Lead Impedancementioning

confidence: 99%

Intraprocedural Assessment of Stimulation, Sensing, Detection, and Defibrillation

Rizkallah¹,

Exner²

2017

Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy

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“…ECG criteria have been studied previously and led to highly variable conclusions, [2][3][4]10,14,15 rendering its use subject to caution for RV lead positioning. However, the inaccuracy of the classical fluoroscopy criteria has also been previously shown in several studies, using either TTE 2 or computed tomography scan 3,4 as a reference.…”

Section: Flaws Of the Usual Per-procedural Tools For Targeting The Rvmentioning

confidence: 99%

“…1 During the implantation procedure, fluoroscopy criteria are routinely used to target the RV septum, with the most useful fluoroscopy projection being the left anterior oblique (LAO) 40°, which is thought to see the heart along its long-axis and thus offers a profile view of the interventricular septum. However, the classical fluoroscopy criteria have proven to be unreliable in several studies, [2][3][4] with frequent RV leads positioned on the RV free wall despite fluoroscopy indicating a septal position, hence raising major concern about the safety and the efficacy of usual fluoroscopy criteria for RV lead positioning.…”

mentioning

confidence: 99%

Individualized Left Anterior Oblique Projection

Squara

Scarlatti

Riccini

et al. 2018

Circ: Arrhythmia and Electrophysiology

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BACKGROUND:Classical fluoroscopic criteria for the documentation of septal right ventricular (RV) lead positioning have poor accuracy. We sought to evaluate the individualized left anterior oblique (LAO) projection as a novel fluoroscopy criterion. METHODS:Consecutive patients undergoing pacemaker or defibrillator implantation were prospectively included. RV lead positioning was assessed by fluoroscopy using posteroanterior, right anterior oblique 30° to rule out coronary sinus positioning, and LAO 40° in the classical group or individualized LAO in the individualized group. Individualized LAO was defined by the degree of LAO that allowed the perfect superposition of the RV apex (using the tip of the RV lead temporarily placed at the apex) and of the superior vena cava-inferior vena cava axis (materialized by a guidewire), hence providing a true profile view of the interventricular septum. Accuracy of fluoroscopy for RV lead positioning was then assessed by comparison with true RV lead positioning using transthoracic echocardiography. RESULTS:We included 100 patients, 50 in each study group. Agreement between RV lead septal/free wall positioning in transthoracic echocardiography and fluoroscopy was excellent in the individualized group (k=0.91), whereas it was poor in the classical group (k=0.35). Septal/free wall RV lead positioning was correctly identified in 48/50 (96%) patients in the individualized group versus 38/50 (76%) in the classical group (P=0.004). For septal lead positioning, fluoroscopy had 100% Se and 89.5% Sp in the individualized group versus 91.4% Se and 40% Sp in the classical group. Complications and procedural data were comparable in both groups. CONCLUSION:Individualized LAO is a quick and highly reliable patienttailored fluoroscopy projection for RV lead positioning.

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Accuracy of Fluoroscopic and Electrocardiographic Criteria for Pacemaker Lead Implantation by Comparison with Three-Dimensional Echocardiography

Cited by 25 publications

References 27 publications

Electrocardiographic predictors of validated right ventricular outflow tract septal pacing for correct localization of transthoracic echocardiography

Electrocardiographic predictors of validated right ventricular outflow tract septal pacing for correct localization of transthoracic echocardiography

Intraprocedural Assessment of Stimulation, Sensing, Detection, and Defibrillation

Individualized Left Anterior Oblique Projection

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