Key result
TTE-guided fluoroscopy-free pacemaker implantation achieves acute procedural success in ~97% of patients.
Why the study?
A standardized transthoracic echocardiography-only workflow for transvenous permanent pacemaker implantation has not been prospectively evaluated.
Does transvenous permanent pacemaker implantation guided exclusively by TTE without fluoroscopy provide feasible and safe outcomes in selected patients with pacing indications?
Does transvenous permanent pacemaker implantation guided exclusively by TTE without fluoroscopy provide feasible and safe outcomes in selected patients with pacing indications?
Transthoracic echocardiography-guided, fluoroscopy-free permanent pacemaker implantation is feasible and has acceptable acute safety in selected patients with adequate acoustic windows.
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“To our knowledge, this is the first prospective feasibility study to evaluate a standardized, fully transthoracic workflow for conventional transvenous pacemaker implantation without intraprocedural fluoroscopic guidance," write the authors. "TTE provided step-specific, two-dimensional structural visualization.”
TTE-only pacemaker implantation may be feasible in select cases; leaves open broader safety and efficacy before practice consideration.
BACKGROUND: Fluoroscopy is routinely used for transvenous permanent pacemaker implantation, but a standardized transthoracic echocardiography (TTE)-only workflow has not been prospectively evaluated. OBJECTIVES: The objective of the study was to evaluate the feasibility, acute safety, and procedural performance of fluoroscopy-free transvenous pacemaker implantation guided exclusively by TTE. METHODS: In this prospective, single-center feasibility study (RADIANCE [Radiation-free Anatomical Direct Imaging Approach for No-fluoroscopy Cardiac Electrode Implantation]; NCT07458724), 52 consecutive patients referred to the Department of Structural Heart Disease were screened. Thirty-one selected patients (59.6%) with guideline-based pacing indications and adequate prespecified supine TTE acoustic windows underwent attempted TTE-only implantation. Acute procedural success required completion without fluoroscopic conversion and fulfillment of prespecified TTE-defined anatomical, electrical, and safety criteria. RESULTS: TTE-only implantation was successful in 30/31 patients (96.8%; 95% CI: 83.3-99.9), with fluoroscopic conversion in 1/31 (3.2%). The mean procedure time was 55.4 ± 5.6 minutes. No major acute procedural complications occurred. During a median follow-up of 8.8 months (IQR: 6-12 months), atrial lead dislodgement requiring revision occurred in 1/21 dual-chamber recipients (4.8%; 95% CI: 0.1-23.8). Procedure time decreased with chronological case order (-0.59 minutes/case; Newey-West 95% CI: -0.68 to -0.49), an exploratory team-level association. CONCLUSIONS: In selected patients with adequate supine acoustic windows, TTE-guided fluoroscopy-free pacemaker implantation was feasible with acceptable acute outcomes. The lead-position findings and exploratory case-order association require further validation in larger and more diverse populations.
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Feng et al. (2026) studied Guideline-based pacing indications (n=31). Transthoracic echocardiography (TTE)-guided transvenous permanent pacemaker implantation without fluoroscopy was evaluated on Acute procedural success (completion without fluoroscopic conversion and fulfillment of prespecified criteria) (95% CI 83.3-99.9). Transthoracic echocardiography-guided fluoroscopy-free pacemaker implantation was highly feasible, achieving acute procedural success in 96.8% of patients (95% CI 83.3-99.9).
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