Can QRS morphology be used to differentiate between true septal vs. apparently septal lead placement? An analysis of ECG of real mid-septal, apparent mid-septal, and apical pacing

Anna Mala, Pavel Osmancik, Dalibor Herman, Karol Curila, Petr Stros, Jana Vesela, Radka Prochazkova, Robert Petr, Anna Mala, Pavel Osmancik, Dalibor Herman, Karol Curila, Petr Stros, Jana Vesela, Radka Prochazkova, Robert Petr

Abstract

The location of the pacemaker lead is based on the shape of the lead on fluoroscopy only, typically in the left and right anterior oblique positions. However, these fluoroscopy criteria are insufficient and many leads apparently considered to be in septum are in fact anchored in anterior wall. Periprocedural ECG could determine the correct lead location. The aim of the current analysis is to characterize ECG criteria associated with a correct position of the right ventricular (RV) lead in the mid-septum. Patients with indications for a pacemaker had the RV lead implanted in the apex (Group A) or mid-septum using the standard fluoroscopic criteria. The exact position of the RV lead was verified using computed tomography. Based on the findings, the mid-septal group was divided into two subgroups: (i) true septum, i.e. lead was found in the mid-septum, and (ii) false septum, i.e. lead was in the adjacent areas (anterior wall, anteroseptal groove). Paced ECGs were acquired from all patients and multiple criteria were analysed. Paced ECGs from 106 patients were analysed (27 in A, 36 in true septum, and 43 in false septum group). Group A had a significantly wider QRS, more left-deviated axis and later transition zone compared with the true septum and false septum groups. There were no differences in presence of q in lead I, or notching in inferior or lateral leads between the three groups. QRS patterns of true septum and false septum groups were similar with only one exception of the transition zone. In the multivariate model, the only ECG parameters associated with correct lead placement in the septum was an earlier transition zone (odds ratio (OR) 2.53, P = 0.001). ECGs can be easily used to differentiate apical pacing from septal or septum-close pacing. The only ECG characteristic that could help to identify true septum lead position was the transition zone in the precordial leads. ClinicalTrials.gov identifier: NCT02412176.

Keywords: Apical pacing; ECG; Pacemaker implantation; Septal pacing.

Published on behalf of the European Society of Cardiology. © The Author(s) 2020.

Figures

Figure 1
Figure 1
Example of paced ECG and computed tomography scans of true mid-septal pacing. (A) ECG of a patient with lead implanted in the septum, (B) the position of the right ventricular lead in the left anterior oblique projection 40° on fluoroscopy during the implant, (C) the position of the right ventricular lead in the right anterior oblique projection 30° on fluoroscopy during the implant, (D) the location of the right ventricular lead in the long axis on computed tomography, and (E) the location of the right ventricular lead in the short axis on computed tomography.
Figure 2
Figure 2
Example of paced ECG and computed tomography scans of ‘false’ septal pacing (i.e. anterior wall). (A) ECG of a patient with lead implanted in the anterior wall of the right ventricle, (B) the position of the right ventricular lead in the left anterior oblique projection 40° on fluoroscopy during the implant, (C) the position of the lead in the right anterior oblique projection 30° on fluoroscopy during the implant, (D) the location of the right ventricular lead in the long axis on computed tomography, and (E) the location of the right ventricular lead in the short axis on computed tomography.
Figure 3
Figure 3
Example of paced ECG and fluoroscopy of apical pacing. (A) ECG of a patient with lead implanted in the apex and (B) the position of the lead in the anteroposterior projection on fluoroscopy during the implant.
Figure 4
Figure 4
Figure plot of the distribution of transition zones in each group. Each column represents a patient group (i.e. true septum, false septum, A) as 100% of patients. The different coloured bars of the plot shows the percentage of patients with a particular transition zone. Black = transition zone in V2 or V3, dark grey = transition zone in V4 or V5, and light grey = transition zone in V6 or later (V7).

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