Preprocedural Computed Tomography Guidance Improves Accuracy of Right Ventricular Septal Lead Placement in Pacemaker Implantation

Introduction Accurate right ventricular septal lead placement is crucial for optimal pacemaker performance and procedural safety, yet conventional fluoroscopy‐guided implantation is limited by inter‐individual anatomical variability. We therefore examined whether preprocedural computed tomography (CT) can provide patient‐specific anatomical guidance to enable precise lead positioning. Methods and Results We retrospectively analyzed 501 consecutive patients who underwent initial dual‐chamber pacemaker implantation for bradycardia pacing (non‐CT‐guided, n = 243; CT‐guided, n = 258). In the CT‐guided group, the midseptal target was determined preoperatively using multiplanar reconstruction of CT images, and reference lines were projected onto the scout image to guide lead placement. We evaluated the total procedure time, fluoroscopy time, right ventricular lead electrical parameters, implantation site, and complications. CT guidance was associated with a higher rate of septal lead placement than non‐CT guidance (93.0% vs. 55.6%, p < 0.001), whereas free‐wall lead placement was less frequent (7.0% vs. 44.4%, p < 0.001). The procedural radiation dose was lower with CT guidance (CT‐guided, 100.2 ± 124.6 mGy vs. non‐CT‐guided, 169.1 ± 152.4 mGy; p < 0.001). Among patients with complete atrioventricular block and available postoperative paced QRS measurements ( n = 303), QRS duration was shorter in the CT‐guided group than in the non‐CT‐guided group (145.3 ± 22.3 ms [ n = 165] vs. 155.4 ± 19.0 ms [ n = 138], p < 0.001). The association persisted after multivariable adjustment ((adjusted OR, 10.30; 95% CI, 5.91–17.97; p < 0.001). The total procedure time, fluoroscopy time, and pacing parameters were comparable between the groups. Complication rates were low overall, and pocket hematoma was less frequent in the CT‐guided group (0.4% vs. 2.9%, p = 0.03). Conclusion Preprocedural CT guidance facilitated precise planning of the right ventricular lead target using scout images and was associated with accurate and reproducible placement at the intended septal site without prolonging procedural time or compromising electrical performance. This approach may represent a practical strategy for optimizing lead placement in bradycardia pacing.