Right ventricular outflow tract pacing: radiographic and electrocardiographic correlates of lead position

To characterize the pacing site in an unselected series of patients undergoing right ventricular outflow tract (RVOT) lead placement and investigate the role of the electrocardiogram (ECG) in predicting implantation.

Right ventricular apical pacing is associated with long-term adverse effects on left ventricular function, fuelling interest in alternative pacing sites, especially the RVOT. Previous studies have been conflicting, possibly due to poor definition of pacing site within the RVOT.

In 150 patients undergoing pacemaker implantation, implanters were asked to place the lead in the RVOT. Radiographs were performed in the antero-posterior (AP) and 40 degrees right and left anterior-oblique projections post procedure. Fifty-six had left lateral radiographs. Lead position was categorized using AP/RAO (right anterior oblique) to confirm RVOT placement and left anterior oblique to distinguish free wall from septum. A 12-lead ECG was performed during ventricular pacing.

Leads were below the RVOT in 18. Of the remaining 132, the majority (94%) were in the inferior/low RVOT. Eighty-one out of 132 were septal and 51 free wall. Septal sites were associated with shorter QRS duration (134 ms vs 143 ms, P < 0.02). Free wall sites displayed more frequent notching of the inferior leads (P < 0.01). A negative deflection in lead I provided a positive predictive value of 90% for septal sites. In those with lateral radiographs, a posteriorly projected lead was 100% specific for septal placement.

This study demonstrates the heterogeneity of lead placement within the RVOT. Septal and free wall sites display characteristic ECG patterns which may be used to aid placement. The left lateral radiograph is useful in confirming a true septal location.