Lead placement atrial

Atrial lead placement directly relates to the type of atrial electrode selected, regardless of fixation mechanism. Similar to the ventricular lead, proper placement is a symphony of the lead and stylet. 

The floppy-tip technique may be used for achieving unusual atrial lead placement with a shaight active fixation lead. This is particularly useful for placement along the right lateral atrial wall. With the curved stylet retracted 1 to 2 in., the lead tip assumes a more lateral position. By simply advancing the lead to a point of contact, the fixation mechanism can be activated and threshold measurements carried out. 

Fig. 4.68 Atrial lead placement through atriotomy and purseslring suture. Atrium and ventricular electrodes are positioned and the atriotomy is secured. (Westerman GR, Van Devanter SH. Transthoracic transatrial endocardial lead placement for permanent pacing. Ann Thorac Surg 1987 43(4) 445-446, with permission.)...

Fig. 4.69 Atrial lead placement. Insert in the upper right shows atrial endocardial lead being placed through the wall of the right atrial appendage with the tip of the pacemaker lead abutting the endocardial surface. A pursestring suture is placed around the lead at the point of entry. The relationship of the atrial lead is also shown. (Hayes DL, Vhetstra RE, Puga FJ, et al. A novel approach to atrial endocardial pacing. Pacing Clin Electrophysiol 1989 12(1 Pt 1) 125-130, with permission.)...

Unlike ventricular lead placement, venous access has little effect on atrial lead positioning. Whether from the right or left venous access, the preformed J or straight electrode with preformed J stylet is easily maneuvered into the atrial appendage or desired position. It should be noted that a right lateral atrial position is more easily achieved by a right venous access. Atrial septal positions are more easily achieved from the left. 

Padeletti L, Purerfellner H, Adler SW, Waller TJ, Harvey M, Horvitz L, Holbrook R, Kempen K, Mugglin A, Hettrick DA. Combined efficacy of atrial septal lead placement and atrial pacing algorithms for prevention of paroxysmal atrial tachyarrhythmia. J Cardiovasc Electrophysiol. 2003 14 1189-1195. 

Bennett et al. reported that atrial activation times were similar when pacing from the CS os, Bachmann s Bnndle or the interatrial septum (30). Of these three options, septal lead placement may be preferable given its relative lack of technical complexity. Indeed, Hermida et al. showed no difference in feasibility and reliability comparing septal and RAA pacing sites, whereas septal pacing was associated with shorter interatrial activation times and reduced left atrial electromechanical delay (36). 

The atrial lead mnst be passed into the systemic venons atrium, which is composed mostly of artificial material in the Mustard procedure. Areas of left atrial tissue are incorporated into the systemic venons atrinm and are available for pacing. The ideal location for placement of an active fixation atrial lead is in the roof of the left atrial portion of the systemic venons atrium, with the lead pointed directly snperior. The tendency of the lead as it crosses the baffle is to be directed against the lateral wall of the left atrium jnst above the mitral annulus, but placement of the lead here almost always allows phrenic stimulation. Directing the lead snperiorly avoids the phrenic nerve (45). 

For both atrial and ventricular leads, it is important that the lead not be too shallow. For ventricular leads, this means that slack left in the lead is inadequate, and a shallow atrial lead implies that the angle of the J is much greater than 90°. In Fig. 18.16, placement of both leads is too shallow. The atrial lead... 

Fig. 18.15 Posteroanteiior (i4) and lateral (B) chest radiographs of a dual-chamber pacing system. The atrial lead is positioned in a septal position (arrow). This patient had extremely long intra-atrial conduction times, and septal placement was the only way to maintain effective atrioventricular synchrony.

In Fig. 18.27, placement of the atrial lead is too shallow, and close observation reveals that the conductor coil of the atrial lead has separated. Atrial pacing was not possible, but surprisingly, atrial sensing remained intact, probably... 

Removal of noninfected leads is not indicated (Class III) if patients have a life expectancy of less than 1 year and in patients with known anomalous placement of leads through structures other than normal venous and cardiac structures (e.g., subclavian artery, aorta, pleura, atrial or ventricular wall, or mediastinum) or through a systemic venous atrium or systemic ventricle. Additional techniques including surgical backup may be used if the clinical scenario is compelling. 

Lead passage and placement via right venous access is intrinsically difficult because of the multiple natural acute angles and bends that are encountered from this approach. Just as a left venous approach forms a gentle C-shaped curve that is counterclockwise, the right venous access results in a clockwise curve that directs the electrode to the right lateral atrial wall when the curved stylet is in place (Fig. 4.34). It then takes considerable skill, ingenuity, and even luck to cross the tricuspid valve. Because the lead tip consistently points to the... 

The second technique involves atrial placement of an active fixation lead that is straight. In this case, desired lead position is achieved by preforming the stylet into a shape that will achieve the desired position. Such leads... 

Aetive fixation extendable rehactable leads that require the lead stylet to be fully advanced for placement preclude the use of this floppy-tip technique. Occasionally, in a setting of a giant right atrium, atrial endocardial lead contact is difficult to achieve. In this circumstance, a stiffer stylet is recommended. This stylet is preformed into a more exaggerated curve. Subsequently, frustration is encountered because the stiffer stylet with a more exaggerated curve will not negotiate the venous system in the superior mediastinum. 

Fig. 16.14 Dislodgment of newly implanted atrial and ventricular pacemaker leads (white arrows) during placement of a Swan-Ganz catheter (black arrow). Both leads are looped up into the right internal jugular vein (white arrowhead) revealing the mechanism of dislodgment the balloon at the tip of the Swan-Ganz catheter was left inflated while it was pulled back towards the venous sheath.

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