Chest Radiographs Are Valuable in Demonstrating Clinically Significant Pacemaker Complications That Require Reoperation Diane Belvin, MD, David Hirschl,

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Chest Radiographs Are Valuable in Demonstrating Clinically Significant Pacemaker Complications That Require Reoperation Diane Belvin, MD, David Hirschl, MD, Vineet R. Jain, MD, Alla Godelman, MD, Marjorie W. Stein, MD, Jay N. Gross, MD, Linda B. Haramati, MD, MS Canadian Association of Radiologists Journal Volume 62, Issue 4, Pages 288-295 (November 2011) DOI: 10.1016/j.carj.2010.04.016 Copyright © 2011 Canadian Association of Radiologists Terms and Conditions

Figure 1 (A, B) Posteroanterior and lateral chest radiographs, with a line that diagrams the expected course of a right ventricular apical pacemaker lead. Canadian Association of Radiologists Journal 2011 62, 288-295DOI: (10.1016/j.carj.2010.04.016) Copyright © 2011 Canadian Association of Radiologists Terms and Conditions

Figure 2 (A, B) Posteroanterior and lateral chest radiographs, with a line that diagrams the expected course of a right ventricular septal pacemaker lead. Canadian Association of Radiologists Journal 2011 62, 288-295DOI: (10.1016/j.carj.2010.04.016) Copyright © 2011 Canadian Association of Radiologists Terms and Conditions

Figure 3 (A, B) Posteroanterior and lateral chest radiographs, with a line that diagrams the expected course of a right atrial appendage pacemaker lead. Canadian Association of Radiologists Journal 2011 62, 288-295DOI: (10.1016/j.carj.2010.04.016) Copyright © 2011 Canadian Association of Radiologists Terms and Conditions

Figure 4 A 64-year-old woman, status post-pacemaker implantation. Anteroposterior portable chest radiograph performed on the day of implantation, showing suboptimal positioning of both leads. The right atrial lead tip is in the region of the superior vena cava (arrowhead) and the j-shape is missing. The right ventricular lead tip (arrow) is in the region of the tricuspid valve. The patient underwent repositioning for high thresholds 3 days later. Canadian Association of Radiologists Journal 2011 62, 288-295DOI: (10.1016/j.carj.2010.04.016) Copyright © 2011 Canadian Association of Radiologists Terms and Conditions

Figure 5 A 74-year-old woman, status post-pacemaker implantation. Three days after implantation, she developed a lead perforation manifest as loss of ventricular capture and a pericardial effusion. (A) Immediate post-implantation posteroanterior chest radiograph, demonstrating the pacemaker leads in the right atrial appendage and right ventricular outflow tract (arrow). (B) Follow-up anteroposterior chest radiograph 1 day after implantation, showing the reorientation of the perforated right ventricular lead tip (arrow), which is within 3 mm of the heart border. Canadian Association of Radiologists Journal 2011 62, 288-295DOI: (10.1016/j.carj.2010.04.016) Copyright © 2011 Canadian Association of Radiologists Terms and Conditions

Figure 6 A 70-year-old man with a left fibrothorax underwent pacemaker implantation and required reoperation for atrial lead displacement nearly 2 months later. (A) Anteroposterior chest radiograph 9 days after pacemaker implantation, showing the right atrial lead to be located in the lateral atrium. (B) Follow-up anteroposterior chest radiograph 33 days after implantation, demonstrating displacement of the atrial lead into the right ventricle (arrow). Canadian Association of Radiologists Journal 2011 62, 288-295DOI: (10.1016/j.carj.2010.04.016) Copyright © 2011 Canadian Association of Radiologists Terms and Conditions

Figure 7 A 76-year-old woman from the control group underwent pacemaker implantation. The pacemaker continued to function well at 1 year. (A) Immediate post-implantation posterolateral chest radiograph, showing the right atrial lead to be oriented medially (arrow) in the atrium; the ventricular lead is apical. (B) Follow-up posteroanterior chest radiograph 4 months after implantation, showing a clinically insignificant change in the orientation of the atrial lead, from a medial to a lateral (arrow) position. (C) Axial image from a contrast-enhanced computed tomography, showing the ventricular lead tip in the epicardial fat superficial to the right ventricle (arrow) consistent with subclinical perforation; there is no pericardial effusion. Canadian Association of Radiologists Journal 2011 62, 288-295DOI: (10.1016/j.carj.2010.04.016) Copyright © 2011 Canadian Association of Radiologists Terms and Conditions