Individualized Left Anterior Oblique Projection

Abstract

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.

Usefulness of delivery catheter on accurate right ventricular septal pacing: Mt FUJI trial

“…Individualized LAO is a refined method to improve the accuracy of fluoroscopy-guided RV septal lead placement. 10 The degree of individualized LAO is reported to be >60 degrees in the majority of patients (58%). 10 Therefore, LAO of 30°–40° can be insufficient to distinguish the septum from the free wall in most patients.…”

“… 10 Therefore, LAO of 30°–40° can be insufficient to distinguish the septum from the free wall in most patients. The need for the placement of a guidewire through the superior and inferior vena cava and a lead or catheter in the RV apex to calculate individualized LAO in this method 10 may lead to prolongation of procedure and fluoroscopic time.…”

“… 6–8 We recently reported that unexpected RV free-wall pacing could attenuate RV septal pacing efficacy in patients undergoing fluoroscopic-guided RV lead implantation on the RV septum. 7 Some techniques, including the use of the right anterior oblique (RAO) view, 6 , 9 individualized left anterior oblique (LAO) view, 10 and right ventriculography 11 have been advocated to achieve a higher success rate of RV septal pacing. One possible breakthrough is the use of a delivery catheter system.…”

Permanent Cardiac Pacing of the Right Ventricular Outflow Tract Guided by Real-time Assessment of Electromechanical Synchrony

“… 24 The inferior margin can be considered as a line drawn from the superior tricuspid annulus (in whose superior end the His bundle is located) to the interventricular septum. 22 , 25 …”

Comparison of delivery catheter-based and stylet-based right ventricular lead placement at the right ventricular septum under fluoroscopic guidance judged by cardiac CT (Mt. FUJI): a study protocol for the Mt. FUJI randomised controlled trial

“…[7][8][9][10][11] A recent report suggested that unexpected free wall pacing leads to increased occurrence of cardiovascular death and heart failure hospitalisation in patients undergoing RV septal pacing owing to AVB. 7 Recent reports showed that the use of individualised LAO 12 or right ventriculography 13 could improve the CT-judged accuracy of RV lead deployment on the RV septum by over 90%. However, determining the individualised LAO or performing right ventriculography during the procedure could prolong the procedural and fluoroscopic time.…”