Pacemaker Implantation

Pacemaker Implant Anatomy – Step-by-Step (Part 2)

Atrial Lead – Atrial Appendage

Figure 13 shows placement in the atrial appendage. This is the classic position of the atrial lead and often a non-traumatic (passive) J-shaped lead is used for this purpose.

Figure 13: The illustration above shows placement in the atrial appendage. This is the classic position of the atrial lead and often a non-traumatic (passive) J-shaped lead is used for this purpose.

Figure 13: The illustration above shows placement in the atrial appendage. This is the classic position of the atrial lead and often a non-traumatic (passive) J-shaped lead is used for this purpose.

Figure 14: Non-Traumatic (passive) Fixation

Figure 14: Non-Traumatic (passive) Fixation

Figure 15: Non-Traumatic (passive) Fixation

Figure 15: Non-Traumatic (passive) Fixation

All manufacturers make a passive atrial lead with a preformed J (refer to Figures 14 and 15) to aid positioning into the atrial appendage, however if an active lead is needed not all manufacturers make a lead with a preformed J. When a straight lead is used a curved stylet is used to aid manipulation to attain a proper position with the atrium.

In Figure 16, active fixation is used. One can clearly see the screw protruding from the tip of the lead. After fixation is established, the stylet can be withdrawn. Thereafter the lead will show its final curve.
Note that different brands of lead have a typical appearance on fluoroscopy. Even different models from the same manufacturer can have different radiological appearances.

When introducing a J-shaped pre formed lead on fluoroscopy. The entrance of the appendage is somewhat lower than one would expect. When the “windscreen wiper” movement is observed, the lead is in the proper position. About a 5 o’clock position (refer to Figure 17) will allow the lead to enter the right atrial appendage.

The pathology specimen (Figure 18) of the non-traumatic lead clearly shows how well the tines of the lead lodge the tip in the right atrial appendage. Tines provide ample pressure to establish close contact between the tip and endocardium of the atrial appendage.

Figure 16: Active Fixation (see screw)

Figure 16: Active Fixation (see screw)

Figure 17: Atrial lead at 5 o'clock position

Figure 17: Atrial lead at 5 o'clock position

Figure 18

Figure 18

 

Continue to Part 3

Author:

Stuart Allen
Principal Cardiac Physiologist
Manchester Heart Centre
Manchester, UK

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