Comparison of tools and techniques for implanting pacemaker leads on the ventricular mid-septum

Many physicians target the interventricular septum for pacemaker implantation, but the lead may inadvertently end up in an anterior position. We sought to compare two stylet shapes to achieve mid-septal lead placement, as well as the utility of a novel right anterior oblique (RAO) fluoroscopic landmark. Patients undergoing pacemaker implantation were enrolled into four consecutive groups according to stylet shape: a standard curve two-dimensional (2D) stylet or with an additional distal posterior curve three-dimensional (3D) stylet, and whether RAO fluoroscopy was used. Left oblique anterior (LAO) and postero-anterior (PA) fluoroscopic views were used in all cases. After implantation, validation of right ventricular lead position (septal vs. anterior) was performed by echocardiography. A total of 113 patients were included, of whom lead position could be validated in 106 patients. Septal position was achieved in only 10 of 22 (45%) patients in the 2D stylet group and in 17 of 23 (74%) patients in the 3D stylet group (P= 0.07) when only PA and LAO fluoroscopy were used. Results were significantly improved by additional use of RAO fluoroscopy, with successful septal placement in 25 of 28 (89%) patients in the 2D stylet + RAO group (P= 0.001) and 32 of 33 (97%) patients in the 3D stylet + RAO group (P= 0.015). A septal lead position was obtained in only about half of the patients when a 2D stylet was used with only LAO and PA fluoroscopic views. A 3D stylet was useful to attain the target position, and additional RAO fluoroscopy significantly improved success rate with both stylet shapes.