Ventricular septal pacing: Optimum method to position the lead

Abstract

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.

Exploratory use of intraprocedural transesophageal echocardiography to guide implantation of the leadless pacemaker

“…Traditionally, right anterior oblique/left anterior oblique orthogonal views in fluoroscopy are used for pacemaker lead positioning within the IVS, and IV contrast is used to visualize RV landmarks such as the RV apex. 15 We used IV contrast in the majority of our cases besides intraprocedural TEE, yet the final LP position in relation to the fluoroscopic RV landmarks was difficult to quantitate, so we did not perform any comparison of TEE RV-LP landmarks and fluoroscopic RV landmarks.…”

Short term outcomes with dual chamber versus single chamber pacing for atrioventricular block - A crossover trial

“… 8 The reason for low incidence of pacemaker syndrome in our study might be the low incidence of VA conduction in patients with AV block and the RV mid septal lead position in most patients leading to reduced V–V dyssynchrony. 10 , 11 …”

Right ventricular lead sensing latency in pacemaker therapy

“…The optimal RV lead position was confirmed by combined fluoroscopy views and characteristic paced ECG criteria. 10 , 11 …”

“…The same bipolar steroid‐eluting active fixation RV pacing lead of the same brand (Medtronic 4076, tip electrode surface area 4.2 mm 2 or Abbott 2088TC, tip electrode surface area 6.9 mm 2 , both of 58 cm length with tip to ring spacing 10 mm), was used for RV mid‐septal placement. The optimal RV lead position was confirmed by combined fluoroscopy views and characteristic paced ECG criteria 10,11 …”

“…The optimal RV lead position was confirmed by combined fluoroscopy views and characteristic paced ECG criteria. 10,11 Note that in order to obtain optimal results, each pacemaker manufacturer supplies PSAs with band-pass filters that match the filters used in their pacemaker systems. 1 PSA cable connections (Medtronic model 5833SL of 3.66 m length and St. Jude Medical model 4051 L of 3.7 m length, respectively) were used to display the EGM through the implanted RV lead in bipolar mode by using crocodile clips on the lead terminal pins.…”