Validation of Conventional Fluoroscopic and ECG Criteria for Right Ventricular Pacemaker Lead Position Using Cardiac Computed Tomography

“…However, the left ventricle was displaced to the left, and the left-sided angle between the interventricular septum and horizontal axis of the body reduced to 16° by chest CT. We proposed that, in clockwise rotated heart patients, left lateral radiograph was not useful in confirming a true septal location. Some recent studies [13,14] reported that a schema developed to define septal position in the right anterior oblique fluoroscopic view have high agreement with CT images, differently from that in ECG criteria, although we cannot present this view at the end of pacemaker implantation in our case.…”

Section: Discussionmentioning

confidence: 61%

Pacemaker Lead Perforation during Right Ventricular Outflow Tract Pacing -Importance of Heart Rotation at Pacemaker Implantation

Watanabe¹,

Shinoda²,

Ikeoka³

et al. 2016

J Clin Case Rep

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A 70 year-old woman underwent a dual-chamber pacemaker implantation for episodes of transient block and syncope. The transitional zone of her ECG was observed between V4 and V5, indicating clockwise rotation. An experienced physician performed the Right Ventricular Outflow Tract (RVOT) pacing using an active fixation lead without any immediate complications. For RVOT pacing, the lead was placed approximately two-thirds of the distance from the apex to the pulmonary valve in the postero-anterior view and pointing towards the septum in the left anterior oblique view. The ECG revealed a narrow QRS (120 msec) and the lead I morphology was minus-plus. Six days post-implant, a pacemaker interrogation revealed ventricular undersensing and loss of capture with high output pacing. Chest computed tomography revealed the left ventricle was displaced to the left and the left-sided angle between the interventricular septum and horizontal axis of the body was reduced to 16°. It confirmed an RV lead perforation through the RVOT, with 1 cm of the lead positioned outside the heart. We performed a surgical repair. Though ECG and x-rays showed septal pacing, we experienced an unusual case of a subacute myocardial perforation caused by an active fixation lead possibly due to heart rotation. The present case report described a patient with a subacute lead perforation and no hemodynamic instability. It is important for the general cardiologist to pay attention to heart rotation. After implantation, symptoms that can suggest a lead perforation, as major signs such as pericardial effusion are not necessarily present. A pacemaker interrogation shows lower impedance, as well as undersensing or failure to capture the involved chamber in suspicious findings.

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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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Validation of Conventional Fluoroscopic and ECG Criteria for Right Ventricular Pacemaker Lead Position Using Cardiac Computed Tomography

Cited by 62 publications

References 36 publications

Long-term right ventricular implantable cardioverter-defibrillator lead performance in arrhythmogenic right ventricular cardiomyopathy

Long-term right ventricular implantable cardioverter-defibrillator lead performance in arrhythmogenic right ventricular cardiomyopathy

Pacemaker Lead Perforation during Right Ventricular Outflow Tract Pacing -Importance of Heart Rotation at Pacemaker Implantation

Individualized Left Anterior Oblique Projection

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