Inadequacy of fluoroscopy and electrocardiogram in predicting septal position in RVOT pacing – Validation with cardiac computed tomography

Sharma, Gautam; Salahuddin, Salman; Sanders, Prashanthan; Gupta, Himanshu; Gulati, Gurpreet Singh; Jagia, Priya; Bahl, Vinay K.

doi:10.1016/j.ihj.2015.10.382

Cited by 18 publications

(17 citation statements)

References 15 publications

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“…Recently, several studies have indicated the inadequacy of the LAO view alone in predicting septal location of the RV lead. 21 , 26 , 29 In 50 patients, Margulescu et al have studied RV lead positions using fluoroscopic 40 ° LAO projection to differentiate between septal and free wall and fluoroscopic RAO 40 ° view to define the lead position in RVOT, mid-ventricular or RV apex. 21 The exact anatomic position of the RV lead was documented using 3-dimensional trans -thoracic echocardiography.…”

Section: Fluoroscopic Approachmentioning

confidence: 99%

Ventricular septal pacing: Optimum method to position the lead

Das

Kahali²

2018

Indian Heart Journal

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Adverse hemodynamics of right ventricular (RV) pacing is known for years. Several studies have revealed that adverse outcomes of RV apical pacing are directly linked to cumulative percentage of ventricular pacing. Algorithms to minimize ventricular pacing are only effective if there is good atrioventricular (AV) conduction. A need for an alternate site for ventricular pacing is evident in patients with high presumed ventricular pacing burden. Most studied alternate site for ventricular pacing is ventricular septum (outflow tract septum and mid-septum). Conventionally septal position of the ventricular pacing lead is confirmed by fluoroscopic appearance of the lead and characteristics electrocardiographic (ECG) features. However, several recent studies have challenged these fluoroscopic and ECG features as to be inadequate. So, there is need for a systematic approach for septal positioning of the ventricular lead.

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Section: Fluoroscopic Approachmentioning

confidence: 99%

Ventricular septal pacing: Optimum method to position the lead

Das

Kahali²

2018

Indian Heart Journal

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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.…”

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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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“…Recently, there have been reports of serious cerebral infarction during cryoballoon (CB) ablation procedures . Cerebral infarction may be caused by air embolism, with the severity of the cerebral infarction depending on the volume of injected air …”

Section: Introductionmentioning

confidence: 99%

“…Recently, there have been reports of serious cerebral infarction during cryoballoon (CB) ablation procedures. [1][2][3][4] Cerebral infarction may be caused by air embolism, with the severity of the cerebral infarction depending on the volume of injected air. 5 On August 30, 2018 the Japanese Heart Rhythm Society issued an emergency alert stating that the presumed cause of cerebral infarction during CB ablation procedures is a large amount of air entering a steerable sheath (Flex Cath Advance sheath, Medtronic, Minneapolis, MN) while using noncryoballoon catheters (ie, catheters not designed exclusively for use with a steerable sheath for CB ablation).…”

mentioning

confidence: 99%

Prevention of serious air embolism during cryoballoon ablation; risk assessment of air intrusion into the sheath by catheter selection and change in intrathoracic pressure: An ex vivo study

Tsukahara

Oginosawa

Fujino

et al. 2019

Cardiovasc electrophysiol

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Introduction One cause of cerebral infarction during cryoballoon ablation is the entry of air into a sheath due to the use of inappropriate catheters. It is known that the left atrial pressure of patients with obstructive sleep apnea syndrome can be negative. However, the effects of catheter selection and negative pressure changes in the sheath on air intrusion are not yet well understood. The aim of this study was to evaluate how catheter selection and negative pressure changes affect air intrusion and to perform countermeasures for air intrusion. Methods and Results This experiment used siphon principle to create negative pressure in the sheath. Noncryoablation catheters (not designed exclusively for cryoballoon ablation) and cryoballoon catheters were investigated. Catheters were inserted into the sheath and then removed. Thereafter, the amount of air in the sheath was measured. For catheters producing significantly larger amounts of air intrusion, the catheters were inserted via a long sheath in the sheath (sheath‐in‐sheath technique) and the same procedures were repeated. We found that the amount of air intrusion through most of the noncryoablation catheters was significantly larger than that through cryoablation catheters. An increase in the magnitude of negative pressure in the sheath resulted in a proportional increase in air intrusion, but the sheath‐in‐sheath technique significantly reduced air intrusion. Conclusion The amount of air intrusion increased when using catheters with complicated tip shapes and thin outer diameters and when the magnitude of negative pressure in the sheath increased. The sheath‐in‐sheath technique may be an effective countermeasure.

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Inadequacy of fluoroscopy and electrocardiogram in predicting septal position in RVOT pacing – Validation with cardiac computed tomography

Abstract: This study, using validation with CTA, showed that conventional ECG criteria and fluoroscopy are inaccurate in differentiating septal from anterior RVOT pacing. The fluoroscopic lateral view, as corroborated by CTA, is more reliable than the LAO view in predicting septal lead placement.

Cited by 18 publications

References 15 publications

Ventricular septal pacing: Optimum method to position the lead

Ventricular septal pacing: Optimum method to position the lead

Individualized Left Anterior Oblique Projection

Prevention of serious air embolism during cryoballoon ablation; risk assessment of air intrusion into the sheath by catheter selection and change in intrathoracic pressure: An ex vivo study

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