Transesophageal 3-dimensional echocardiographic guidance for pacemaker lead placement improves lead position accuracy and reduces fluoroscopy

Abstract

Background: Pacemaker and implantable cardioverter-defibrillator (ICD) lead placement traditionally uses fluoroscopy, often with inaccurate lead placement on the free wall rather than on the ventricular septum, with associated longer QRS duration and pacemaker-induced cardiomyopathy while exposing staff and patients to radiation.

Objective: We sought to determine whether transesophageal 3-dimensional echocardiography (3DE) guidance improves lead placement accuracy in the ventricular septum, results in shorter paced QRS durations, and reduces fluoroscopy exposure.

Methods: In a single-center case-control study, 3DE guided right ventricular or atrial pacemaker and ICD leads to the desired location, with fluoroscopy used per operator preference. Ventricular lead location, paced QRS duration, and fluoroscopy times were recorded and compared with historical controls that used only fluoroscopy during procedures.

Results: In 59 patients, 3DE guidance substantially improved ventricular lead placement in the septum (78.4% vs 29.8%; P < .001) rather than in the free wall (3.9% vs 57.4%; P < .001) compared with 72 historical controls; this difference was more pronounced when only pacemaker leads were considered (90.2% vs 39.4% [P < .001] for septal and 2.4% vs 45.5% [P < .001] for free wall locations). Compared with controls, 3DE guidance reduced fluoroscopy times (6.6 vs 11.2 minutes for all leads [P = .005] and 4.7 vs 9.5 minutes for right ventricular leads [P = .014]) and trended toward shorter paced QRS durations (133 ms vs 141.5 ms; P = .084).

Conclusion: For pacemaker and ICD lead placement, 3DE guidance substantially improves the accuracy of lead placement in the septum, with a shorter QRS duration, while reducing fluoroscopy exposure.

Keywords: 3-dimensional echocardiography; Electrophysiology; Pacemaker; Pediatrics; Transesophageal echocardiography.