Author + information
- Received May 1, 2019
- Revision received June 17, 2019
- Accepted June 19, 2019
- Published online October 16, 2019.
- Dale A. Burkett, MD∗ (, )
- Pei-Ni Jone, MD and
- Kathryn K. Collins, MD
- Division of Cardiology, Heart Institute, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
- ↵∗Address for correspondence:
Dr. Dale A. Burkett, Division of Cardiology, Children’s Hospital Colorado, 13123 East 16th Avenue, B-100, Aurora, Colorado 80045.
The feasibility of transesophageal 3-dimensional echocardiography to reduce fluoroscopy in pacemaker lead placement has not yet been evaluated. This clinical vignette demonstrates the ability of 3-dimensional echocardiography to visualize intracardiac anatomy and the pacemaker lead and to guide positioning of the lead into the right atrial appendage, thus reducing fluoroscopy by nearly 50%. (Level of Difficulty: Advanced.)
- pacemaker lead placement
- 3-dimensional echocardiography
- transesophageal echocardiography
Transesophageal 3-dimensional echocardiography (3DE) can detail intracardiac anatomy, devices, catheters, and leads. The authors have used 3DE to guide right-sided heart catheterization and atrial septal defect closure, with reduced radiation exposure to patients (1). Fluoroscopy is also used for pacemaker lead placement, although the utility of 3DE in such procedures has not yet been evaluated. They assessed the feasibility of 3DE to localize and guide right atrial (RA) lead placement.
A 14-year-old male patient with a history of a muscular ventricular septal defect and aortic coarctation that were repaired in infancy, with subsequent sinus node dysfunction, presented for placement of a transvenous endocardial RA lead and left infraclavicular pacemaker generator to be performed using general anesthesia. A total of 4.1 min of fluoroscopy, but no echocardiography, was used for lead placement. A subsequent infection of the newly placed system necessitated complete removal and 4 weeks of intravenous antibiotics. He presented 2 months later for a new transvenous endocardial RA lead (using the same model lead, Boston Scientific 7740, Boston Scientific, Marlborough, Massachusetts) and right infraclavicular pacemaker generator to be placed using general anesthesia, although this procedure was guided by 3DE.
Under guidance from live 3DE on a Philips Epiq platform with X7-2t probe (Philips, Amsterdam, the Netherlands), the right superior vena cava, right atrium, and RA appendage were demonstrated from a ∼110° bicaval window (Figure 1A). 3DE demonstrated the RA lead (Figure 1B), and it guided lead positioning into the anterior RA appendage, by using the 0° and 110° windows (Figures 1C and 1D); the lead was successfully inserted. Only 2.1 min of fluoroscopy was used, to confirm lead location, amount of lead slack, and screw deployment into the RA appendage. Total 3DE guidance duration from central venous access (with wire visualization in the superior vena cava) to insertion of the RA lead was 22 min. The lead demonstrated an impedance of 790 ohms, sensing of 2.2 mV, and pacing threshold of 0.6 V at 0.4 ms. A chest x-ray confirmed lead location the following day (Figures 1E and 1F). The patient tolerated the procedure and has since done well clinically over the last 4 months, with normal lead function, no symptoms, and no exercise intolerance.
The authors demonstrate the feasibility of a novel 3DE application, with substantial potential for radiation reduction in pacemaker lead placement procedures. 3DE clearly visualizes pertinent intracardiac anatomy, and the RA lead in real time and can guide leads to the appropriate location for insertion. 3DE aided in effectively halving the fluoroscopy time compared with a nearly identical procedure completed months previously without 3DE. Further reductions of fluoroscopy and 3DE guidance time are likely with increasing familiarity with the procedure; elimination of fluoroscopy is conceivable. A collaborative approach and clear communication are necessary to ensure successful 3DE comprehension and procedural guidance.
The authors have reported that they have no relationships relevant to the contents of this paper to declare.
- Abbreviations and Acronyms
- 3-dimensional transesophageal echocardiography
- right atrium
- Received May 1, 2019.
- Revision received June 17, 2019.
- Accepted June 19, 2019.