Baylor University Medical Center Proceedings April 2017 - 231

b

a

Figure 1. Right atrial lead threshold testing showing inappropriate right ventricular capture with maximum right atrial output.

Figure 2. An electrocardiogram showing mode DDD, 80 beats per minute, biventricular pacing, right
ventricle/left ventricle, 2 volts at 0.5 milliseconds, right atrium; 1 volt at 0.9 milliseconds.

a

b

RA capture and loss of atrial kick along with 0%
biventricular pacing explained why this patient
was a CRT nonresponder.
Previous reports have discussed two similar
concepts: "cross-stimulation," described as capture of the RV by high-output RA pacing due to
malposition of the RA lead in the anterior tricuspid annulus (1), and "intermittent capture" of the
RV outflow tract from a malpositioned RA lead
in the anteromedial RA (2). The RA appendage
lies adjacent to the RV outflow tract, making it
challenging at times to evaluate the location of the
tip of the pacing lead on fluoroscopy or chest radiography. A noncontrast computed tomography
scan might be beneficial in these scenarios, highlighting the importance of lead position verification prior to a diagnosis of CRT nonresponder.
Care of HF patients undergoing device
therapy should be an integrated approach involving HF and electrophysiology specialists during
routine follow-up. Periodic device interrogations,
electrocardiogram, and multimodality imaging
should be used in these patients prior to premature diagnosis of CRT nonresponse. A more
careful review of fluoroscopic images in different
views and careful attention to the evoked response
to pacing in a given chamber are the key elements
in reducing the rate of CRT nonresponse.
1.

2.

Figure 3. Noncontrast cardiac computed tomography scans with (a) coronal view and (b) sagittal view
showing the tip of the right atrial (RA) lead abutting the base of the right ventricular (RV) outflow tract.
April 2017

Sela R, Stambler B. Cross-stimulation due to malposition of an atrial lead of a dual-chamber pacemaker.
Pacing Clin Electrophysiol 2012;35(1):100-103.
Pastori JD, Garro HA, Baranchuk A, Chiale PA. Intermittent capture of the right ventricular outflow
tract by atrial pacing in a patient with a dual-chamber
pacemaker. J Electrocardiol 2012;45(6):787-789.

Successful treatment of a cardiac resynchronization therapy nonresponder by identifying lead malpositioning

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