Review

Detecting and managing device leads inadvertently placed in the left ventricle

Richard G. Trohman, MD, MBA and Parikshit S. Sharma, MD, MPH
Cleveland Clinic Journal of Medicine January 2018, 85 (1) 69-75; DOI: https://doi.org/10.3949/ccjm.85a.17012

Article Figures & Data

Figures

  • Figure 1
    Figure 1

    Typical 12-lead electrocardiogram showing right bundle branch block morphology from the right ventricular apex with (A) standard V1 and V2 lead positions and (B) return to left bundle branch block morphology after V1 and V2 are moved 1 interspace lower than standard.

  • Figure 2
    Figure 2

    (A) Electrocardiogram from a patient with known left ventricular lead position through a patent foramen ovale. Arrows point to dominant R waves in leads V1, V2, and V3, compatible with left ventricular pacing. (B) The same patient after revision and placement in the right ventricle. Arrows point to dominant R waves in leads V1 and V2, with a precordial transition to a dominant S wave occurring at lead V3.

  • Figure 3
    Figure 3

    (A) Normal lead positions in a cardiac resynchronization therapy defibrillator device on a posteroanterior chest radiograph. An adapter has been added to a pre-existing right-sided atrial lead that has been tunneled to the left-sided pocket. Note that the right ventricular (white arrow) and left ventricular (black arrow) leads appear to overlap. (B) On the lateral chest radiograph, the left ventricular lead is correctly positioned posteriorly (black arrow) and the right ventricular lead is positioned anteriorly (white arrow). (C) In this graphically enhanced image, a ventricular lead has passed through a patent foramen ovale and is positioned posteriorly in the left ventricle endocardium (blue arrow).

    Adapted with permission from references 14 and 15.

  • Figure 4
    Figure 4

    Left, correctly positioned and malpositioned leads. As shown in the transesophageal echocardiogram (right), the malpositioned lead passed through an atrial septal defect (top) through the mitral valve into the left ventricle (bottom).

Tables

  • TABLE 1

    Electrocardiographic localization of leads that exhibit right bundle branch block morphologies during pacing

    Frontal axisPrecordial transitionLocationSensitivity (%)Specificity (%)Positive predictive value (%)
    0° to –90°By V3RV septum or apex869995
    By V4RV septum or apex1009264
    By V4Posterior LV or coronary vein268336
    After V4Posterior LV or coronary vein72100100
    −90° to –180°By V3LV apex and distal anterior LV85100100
    90° to 180°Proximal anterior and anterolateral LV1009790

    • LV = left ventricular; RV = right ventricular

    • Reprinted from reference 6 with permission.

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