Korean J Radiol.  2011 Oct;12(5):611-619. 10.3348/kjr.2011.12.5.611.

Where Does It Lead? Imaging Features of Cardiovascular Implantable Electronic Devices on Chest Radiograph and CT

• Lanzman RS
• Winter J
• Blondin D
• Furst G
• Scherer A
• Miese FR
• Abbara S
• Kropil P

• KMID: 1116447
• DOI: http://doi.org/10.3348/kjr.2011.12.5.611

Abstract

Pacemakers and implantable cardioverter defibrillators (ICDs) are being increasingly employed in patients suffering from cardiac rhythm disturbances. The principal objective of this article is to familiarize radiologists with pacemakers and ICDs on chest radiographs and CT scans. Therefore, the preferred lead positions according to pacemaker types and anatomic variants are introduced in this study. Additionally, the imaging features of incorrect lead positions and defects, as well as complications subsequent to pacemaker implantation are demonstrated herein.

Keyword

Pacemaker; ICD; Chest; Radiograph; CT

MeSH Terms

Aged
Aged, 80 and over
Cardiac Pacing, Artificial
*Defibrillators, Implantable/adverse effects
Female
Humans
Male
Middle Aged
*Pacemaker, Artificial/adverse effects
*Radiography, Thoracic
*Tomography, X-Ray Computed

Figure

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  Fig. 1 Cardiovascular implantable electronic devices consists of one or more leads (black arrows) connected to pulse generator (white arrow).

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  Fig. 2 75-year-old female patient with single lead ventricular pacemaker (VVI). Posteroanterior (PA) and lateral chest radiographs show preferred tip position in apex of right ventricle (arrows).

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  Fig. 3 72-year-old female patient with single lead atrial pacemaker (AAI). PA and lateral chest radiographs show preferred tip position in right atrial appendage (arrows). Note that lead typically curves superiorly and anteriorly into atrial appendage.

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  Fig. 4 57-year-old female patient with two-lead bichamber pacemaker (DDD). Preferred tip position is right atrial appendage (white arrows) and apex of right ventricle (black arrows), as seen on PA and lateral chest radiographs.

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  Fig. 5 69-year-old male patient with biventricular pacemaker (CRT). PA and lateral chest radiographs show preferred tip position in right atrial appendage (white arrows), apex of right ventricle (black arrows), and in posterior coronary vein at left ventricle (arrowheads).

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  Fig. 6 67-year-old patient with implantable cardioverter defibrillator (ICD). PA and lateral chest radiographs demonstrate preferred tip location in apex of right ventricle (white arrows). Implantable cardioverter defibrillator leads contain one or two coils (*) to enable delivery of energy to myocardium. Proximal coil typically resides within superior vena cava. Note that lead tracks along base of right atrium, curves superiorly as it transverses tricuspid valve, and then turns inferiorly as it enters right ventricle.

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  Fig. 7 77-year-old male patient with persistent left superior vena cava following implantation of dual-chamber implantable cardioverter defibrillator. Right atrium and ventricle are reached via coronary sinus. Note superior vena cava lead (arrows) in persistent left superior vena cava.

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  Fig. 8 53-year-old male patient with DDD pacemaker following mitral and tricuspidal valve annuloplasties. PA and lateral chest radiographs show that right ventricular lead (arrowheads) can traverse tricuspid annuloplasty (arrows).

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  Fig. 9 69-year-old female patient after mechanical tricuspidal valve replacement (TVR, arrows). In this case, placement of ventricular lead (arrowhead) should be via coronary sinus, as seen on PA and lateral chest radiographs.

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  Fig. 10 21-year-old male patient with dual-chamber implantable cardioverter defibrillator following Mustard procedure to correct for transposition of great arteries. Scheme (B) and CT scan performed prior to implantable cardioverter defibrillator placement (C-E) show cardiovascular anatomy. Baffle was constructed to direct venous blood to left atrium (B). Oxygenated blood from pulmonary veins is directed to right atrium (RA) and from there to systemic right ventricle (RV) (B-E). PA and lateral chest radiographs (A) demonstrate leads that course from left brachiocephalic vein into anatomical left atrium (functional right atrium, arrowhead) and into anatomical left ventricle (LV) (functional right ventricle).

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  Fig. 11 77-year-old male patient with dual-chamber implantable cardioverter defibrillator. Initial PA and lateral chest radiographs (A) show displacement of atrial lead (white arrows) into right ventricle. After revision, PA and lateral radiographs (B) show correct lead position in right atrium (black arrows). Note epimyocardial lead over right ventricle (*).

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  Fig. 12 61-year-old male patient with atrial septal defect following implantation of DDD pacemaker. PA and lateral chest radiographs demonstrate correct position of right atrium lead, whereas ventricular lead curves superiorly and to left just above level of right atrial lead (arrowhead). This course is typical for malpositioned lead traversing from right atrium to left atrium via atrial septal defect and then into left ventricle (arrows).

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  Fig. 13 77-year-old male patient with DDD pacemaker. PA chest radiograph shows superiorly facing ventricular lead tip, which is suggestive of malposition in coronary sinus (arrow in PA radiograph). Malposition in coronary sinus over left ventricle is confirmed on lateral radiograph (arrow).

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  Fig. 14 35-year-old male patient after implantation of DDD pacemaker. PA and lateral chest radiographs show loop of ventricular lead in right ventricular outflow tract (arrows), which caused insufficiency of pulmonary valve.

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  Fig. 15 42-year-old male patient with Twiddler syndrome. Initial PA radiograph shows preferred lead position and generator configuration of single lead ventricular pacemaker (VVI) (A). Several months later, winding of pacemaker lead around generator can be seen on PA chest radiograph (B), causing dislodgement of ventricular lead (arrow).

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  Fig. 16 52-year-old male patient with DDD pacemaker. PA chest radiograph shows fracture (arrowhead) of ventricle lead and insulation breach (arrow) of atrial lead in subclavian vein adjacent to clavicle ("subclavian crush syndrome").

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  Fig. 17 59-year-old male with single ventricular lead pacemaker. PA chest radiograph discloses lead fracture and dislodgement of lead fragment into hepatic vein.

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  Fig. 18 82-year-old female patient with DDD pacemaker. Sagittal (A) and transverse (B) CT reconstructions show perforation of atrial pacemaker lead (arrow) with development of significant hemopericardium (*).

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  Fig. 19 59-year-old male patient following DDD pacemaker implantation. Hematopneumothorax (arrows) is seen on PA and lateral chest radiographs on contralateral side of pacemaker generator (A). Additional CT scan confirms hematopneumothorax (B, *) and shows perforation of atrial lead (arrowheads in B, C). (Courtesy of Dr. Keske, Gelsenkirchen, Germany).

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  Fig. 20 84-year-old female patient with DDD pacemaker. Perforation of atrial pacemaker lead is seen on PA chest radiograph (arrow).

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  Fig. 21 84-year-old female patient with DDD pacemaker suffering from diaphragmatic stimulation. PA and lateral chest radiographs (A) indicate correct lead positions. However, asymptomatic perforation of atrial (arrow) and ventricular (arrowhead) lead is seen on contrast-enhanced CT scans (B, C). Note upside-down stomach (*).

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  Fig. 22 61-year-old female suffering from postcardiotomy syndrome. PA chest radiograph of 61-year-old female patient prior to pacemaker implantation shows regular heart size (A). Correct lead position is seen immediately following implantation of DDD pacemaker (B). Three months later, patient suffered from fever and poor cardiac function. Massive pericardial effusion was observed seen on PA chest radiograph (C), which was attributed to postcardiotomy syndrome.

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