Individualized left anterior oblique projection based on pigtail catheter visualization facilitates leadless pacemaker implantation

Background Pacemaker positioning on the right ventricular (RV) septum during implantation is conventionally conducted utilizing two fixed fluoroscopy angles, a 45° left anterior oblique (LAO) and 35° right anterior oblique projection. However, placement location can be suboptimal, especially for leadless pacemakers (LPMs). Objective To evaluate the safety and ease of LPM implantation using individualized LAO projection. Methods Consecutive patients undergoing LPM implantation were prospectively included. The angle of the RV septum was recorded for each patient by studying the angle at which an RV pigtail catheter (RV‐PC) could be seen edge on. This was then used as the preferred LAO projection angle for that patient. We evaluated the success rate and safety of this method. We also compared the RV septum angle as measured by this method versus that measured by chest CT. Results Of the 31 patients (mean age 80.6 ± 7.0 years, 15 females), LPM implantation was successful in 30. The pacemaker was implanted on the RV septum in 29 and on the free wall in one. LPM implantation was abandoned for anatomical reasons in one. Complications were limited to a groin arteriovenous fistula and one deep vein thrombosis. The angle of RV septum as measured by pigtail catheter and chest CT was not significantly different (CT: 54.8 ± 6.0°, RV pigtail catheter: 52.9 ± 6.1°, P = .07). Conclusions Using an RV‐PC to determine the preferred angle of LAO projection facilitates differentiation between the RV septum and free wall, which in turn facilitates optimal LPM placement. In our study, we used a pigtail catheter to orient radiographic angle during leadless pacemaker implantation such that the interventricular septum would be on edge in the LAO projection. Employing this angle made it very easy for even our cardiology fellows in training to implant leadless pacemakers at the optimal site on the septum. To the best of our knowledge, this is the first time a right ventricular pigtail catheter has ever been used in this manner, and we feel that both physicians and patients would benefit from this simple maneuver, which we found to be safe and effective.