A primer on radiological analysis of pacer systems

1. Pacemaker Radiology
Frank W. Meissner, MD, FACP, FACC, FCCP

2. Case Presentation
●84 y/o Caucasian male
●Retired Dentist brought in for
pacemaker replacement
●‘Current’ unit recalled
●CXR reviewed by Cardiologist

3. Pacemaker’s, Where Do I Start?

4. Radiographic Approach
●Bony structures
●Aorta
●Cardiac shadow
●Trachea
●Lung
●Other
●PACING SYSTEM

5. Pacing System- Overall View
●‘Can’ subcutaneous pectoral region
●Ventricular lead @ RV apex
●Atrial lead RA appendage
○‘J’ < 80°
○‘J’ medial AP & anterior Lat Projection
●Anatomical variations
○Persistent left superior vena cava
○Transposition of great vessels

6. Pacing System- Overall View

7. Pulse Generator Position

8. Pulse Generator Migration

9. Low Generator Position, WHY?

10. ‘Twiddler’s’ Syndrome

11. Abdominal Tunneled Lead

12. Pulse Generator ID

16. Xray ID of Pulse Generator

17. Xray ID of Pulse Generator

18. Xray ID of Pulse Generator

19. Xray ID of Pulse Generator

20. Polarity

21. Connector Block

22. Vascular System Entry Point
●Subclavian
●Cephalic vein
●Internal Jugular vein
●External iliac vein

23. Internal Jugular Lead

24. Persistent L-Subclavian Vein

25. Lead Placement

26. Right Atrial Septal Lead-
S/P CABG

27. AAI Pacemaker Lead in LA
Corrected Transposition

28. Lat Good Pacer Placement

29. Inadequate Lead Slack

30. Lead misplacement via
ASD to LV Apex

31. Lead Polarity
●Monopolar
●Bipolar
●Tripolar

32. Monopolar and Bipolar

33. Bifurcated Biopolar Lead System

34. Old Caped Leads

35. Tripolar Lead Tip

36. Monopolar Lead

37. Lead Type
●Passive Fixation
●Active Fixation
●Epimyocardial

38. Active vs Passive Lead

39. Active Fixation Lead

40. Epimyocardial & Transvenous

41. Lead Integrity
●Inspect Lead from connector block to
distal tip
●True fracture
●Pseudo-fracture
●Lead crush

42. Lead Fracture

43. Pseudo-fracture

44. Lead Positioning

45. RV Outflow Tract- VLead

46. RVOT V-lead

47. Unusual Lead Position

48. Unusal Lead Position

49. What’s The Problem?

50. Lead in Coronary Sinus

51. Macro Lead Dislodgement

52. Macro Lead Dislodgement

53. Complications
●Pneumothorax
●Hemothorax
●Lead Perforation
●Cardiac Tamponade

54. Accufix J-Tip Lead

55. Adjunctive Aids
●Venogram
●Ultrasound
●Fluoroscopy

56. Venogram - Occlusion

57. Venogram- Patent Flow

58. Summary
●Inspect Routine CXR, ignoring pacing
system
●Examine pulse generator position
●Identify pulse generator model &
polarity
●Inspect Connector block

59. Summary
●Determine lead position
○Transvenous or epimyocardial
○Atrial or ventricular
○If transvenous
■Cardiac chamber
■Coronary sinus

60. Summary
●Determine lead polarity & type of
fixation
●Evaluate lead integrity
●R/O Specific complications of
implantation