Computed tomography validated right ventricular mid-septal lead implantation using right ventricular angiography

Background: Right ventricular (RV) mid-septal pacing has been proposed as an alternative to RV apical pacing. Fluoroscopic and electrocardiogram criteria are unreliable for predicting the RV mid-septal lead position. This study aimed to define the optimal RV mid-septal pacing site using RV angiography.Methods: We randomized patients undergoing pacemaker implantation (PPM) to the RV angiography-guided group (Group A) or conventional fluoroscopy-guided group (Group F). In Group A, we performed an angiogram in right anterior oblique (RAO 30 degrees), left anterior oblique (LAO 40 degrees), and left lateral (LL) views. We made a 5-segment grid in RAO 30 degrees and LL views and a 3-segment grid in LAO 40 degrees on the angiographic silhouette to define the lead position. Computed tomography (CT) was used to validate the lead tip position in both groups.Results: We enrolled 53 patients (Group A: 26, Group F: 27) with a mean age of 55.9 +/- 12.2 years. CT images validated the lead position in the mid-septum (Group A, 23 [88.5%]; Group F, 11 [40.7%], P = .0003) and anteroseptal (Group A, 3 [11.5%]; Group F, 5 [18.5%], P = .24). In Group F, the lead was in the anterior wall in 9 patients (33.3%) and the right ventricular outflow tract in 2 (7.4%) patients and none in these two positions in Group A. The lead tip in segment one on the angiographic 5-segment grid in RAO 30 degrees and LL views indicated a mid-septal lead position on CT.Conclusions: RV angiography is safe and may be used to confirm the mid-septal lead position during PPM.