Pacemaker implantation using electroanatomical mapping system Carto 3: technical protocol, single centre experience

Abstract Funding Acknowledgements Type of funding sources: None. Background / Purpose:  Three-dimensional electro-anatomical mapping systems (EAM) reduce fluoroscopy exposure during ablation procedures. The aim of this study is to evaluate the security and feasibility of performing pacemaker implantation with EAM routinely on a more regular basis (without fluoroscopy) and to draft a technical protocol to perform these implants. Methods Eight non-selected patients with pacemaker indication that had been referred to the electrophysiology unit of our institution underwent a dual chamber pacemaker implantation with EAM system Carto 3 (Biosense Webster, Irvine, CA, USA). All implants were performed by the same operator and, in all cases, the same lead model was employed.  All difficulties that arose during the implantations were solved applying the actions contained in the protocol described below.  First - Creation of three anatomical maps with Carto 3: venous access, right atrium and right ventricle. Annotate the end of the venous sheath.  Second-  For right ventricle lead positioning, connect the pacemaker lead to the Carto 3 system as an external catheter. Place the right ventricle lead, fix it and perform measurements. Third - Fuse the three maps with the "anatomical merge" tool. Fourth - Using the "design line" tool, draw a line from the tip of the lead to the end of the venous sheath following the expected trajectory of the lead in its correct position. Measure that distance. Calculate (substrate) the theoretically remaining lead. Fifth - With a ruler, measure the portion of the lead remaining out of the sheath. Sixth - Reposition the lead, if necessary. Seventh - Repeat the same procedure for the atrial lead and complete the implant procedure. Finally - Verify leads position with fluoroscopy (optional).  Results : Eight patients received a dual chamber pacemaker, 75% male with a mean age 82,88 ±4,97 years. The most frequent indication was AV block (75%). The implant was performed through cephalic vein access (37,5%), subclavian vein access (50%). Mean procedure time (skin to skin) was 94 ±15 minutes. There were no complications related to the implant nor was it necessary to replace the lead. Conclusions : Pacemaker implantation with Carto 3 is a safe and reliable. The learning curve is not steep and the operator should be confident enough only after a few procedures. The protocol developed facilitates the implant procedure. Fluoroscopy timeCase12345678Fluoroscopy time (s)474786246060Dose area product (Gy*cm2)4,270,3710,0290,0630,0630,020,1230,018Abstract Figure. Carto image: dual chamber pacemaker.