All concepts, explanations, trials, and studies have been
re-written in plain English and may contain errors. I am
not a doctor
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Using Echo to Get That Third Pacer Lead Right

May 30, 2006 - Using real-time echo to guide pacemaker lead
placement may really improve pacing results in CHFers. Now,
about 1/3 of CHFers getting BiV pacers don't improve at all.
This may often be from poor placement of the third lead - the
one that coordinates the heart's pumping chambers. Without
some kind of imaging, doctors implanting these leads don't
know for certain how effective the lead placement is.
	You can get an echo before and after implant but
hey, the thing's already implanted by that second echo, so the
lead placement was still just educated guesswork. If you use
echo DURING the implant to see how the heart reacts to
pacing, you can move the lead to get the best heart pumping
action.
	This was a 10-patient trial. An echo catheter was
slid into the mid-right ventricular wall through the sheath used
for the pacemaker's right atrial lead. Echo was done before
pacing started and then again during CRT (biventricular) pacing.
The left ventricle lead ("third lead") was placed where the echo
showed the most improvement in the heart's pumping action.
	There were no complications. After 6 months, 8
patients had improved heart class and 6 patients had improved
EF. Two of the 3 patients with no EF improvement had no need
for CRT to start with. Why they were getting a 3-lead pacer, I
don't know.
	In one patient, pacing only one ventricle gave better
results than pacing both. One other patient who had seen no
improvement with his CRT pacer before this had a significant
improvement after the third lead was moved using real-time echo.

Source:  Heart Rhythm Society 2006 Scientific Sessions; May 17-20, 2006
Title:     Insertion and optimization of left ventricular pacing leads guided
             by intracardiac ultrasound and velocity vector imaging.
Authors: Gallagher P, Creighton D, Scott A A, et al.