Shown here is a videoscopic view of an active fixation lead being placed into the right atrial appendage (RAA). A stylet is used to orient the lead in the desired location in the RAA. Once there, the helix is extended by rotating the proximal pin of the lead which, in turn, extends the helix out of the tip of the lead body and into the tissue.

Shown here is a close-up videoscopic view of an active fixation lead being placed into the right atrial appendage (RAA). A stylet is used to orient the lead in the desired location in the RAA. Next, the helix (tip electrode) is extended by rotating the proximal pin of the lead which, in turn, extends the helix out of the tip of the lead body and into the tissue. One can see these electrode (helix) movements at the lead tip.

Shown here is a videoscopic view of an active fixation lead being placed into the right ventricular apex (RVA). A stylet is used to orient the lead in the desired location in the RVA. Once there, the helix is extended by rotating the proximal pin of the lead which, in turn, extends the helix out of the tip of the lead body and into the tissue.

Shown here is a close-up videoscopic view of an active fixation lead being placed into the right ventricular apex (RVA). A stylet is used to orient the lead in the desired location in the RVA. Next, the helix (tip electrode) is extended by rotating the proximal pin of the lead which, in turn, extends the helix out of the tip of the lead body and into the tissue. One can see these electrode (helix) movements at the lead tip.

The right atrial appendage (RAA) is the traditional implant site for atrial leads. Shown here is the placement of an active fixation lead (with a helix distal electrode) being placed in the RAA.

Shown here is a fluoroscopic view (continuous X-ray) of the placement of an active fixation lead (with a helix distal electrode) being placed in the RAA. The inset on the lower right shows the simultaneous videoscopic view.

Shown here is a videoscopic view of an active fixation lead being placed into the right atrial appendage (RAA). A stylet is used to orient the lead in the desired location in the RAA. Once there, the helix is extended by rotating the proximal pin of the lead which, in turn, extends the helix out of the tip of the lead body and into the tissue.

Shown here is the fluoroscopic view (continuous X-ray) of an active fixation lead crossing the tricuspid valve from the superior vena cava (SVC); the lead is passed up the right ventricular outflow tract (RVOT) and is eventually placed in the RV apex. The inset on the lower right shows the simultaneous videoscopic view.

The pacing lead is a thin insulated wire that carries the electrical impulse to the heart and information about the heart's natural activity back to the pulse generator. One end of the lead is connected to the pulse generator at the connector block. The other end of the lead is connected to the patient, usually inserted through a vein and placed in the right ventricle or the right atrium of the heart.

The tip of the pacing lead may contain a steroid which reduces inflammation and helps maintain a better electrode-tissue electrical interface.

Shown here is a videoscopic view of a lead that was implanted within a heart 33 weeks prior within the right atrial appendage (RAA); one can visualize a fibrous capsule that has formed over the distal portion of the lead body.

The pacing lead is a thin insulated wire that carries the electrical impulse to the heart and information about the heart's natural activity back to the pulse generator. One end of the lead is connected to the pulse generator at the connector block. The other end of the lead is connected to the patient, usually inserted through a vein and placed in the right ventricle or the right atrium of the heart.

The tip of the pacing lead may contain a steroid which reduces inflammation and helps maintain a better electrode-tissue electrical interface. One or more leads can be used within a given patient, depending on the type of pacemaker prescribed.

Shown here is a videoscopic view of two leads that were implanted within a heart 33 weeks prior, one within the right atrial appendage (RAA) and the other within the right ventricle. One can visualize a fibrous capsule that has formed over the distal portion of the lead body. The view begins in the lead in the right ventricular apex, and continues up through the tricuspid valve where one can see the second lead in the right atrium.

Shown here is the videoscopic view of a dislodgement of an active fixation lead placed in the right atrial appendage (RAA); this requires great force and causes tissue damage thus it is not performed clinically. If clinicians choose to move an active fixation lead, they first retract the helix within the lead body.

Shown here is the fluoroscopic view (continuous X-ray) of a dislodgement of an active fixation lead placed in the right atrial appendage (RAA); this requires great force and causes tissue damage thus it is not performed clinically. If clinicians choose to move an active fixation lead, they first retract the helix within the lead body. The inset on the lower right shows the simultaneous videoscopic view.

Shown here is the dislodgement of a tined fixation lead placed in the right atrial appendage (RAA). During placement, the lead can be easily removed and replaced elsewhere by applying retraction force. Clinical dislodgement rarely occurs, for within hours to days this lead will become fibrosed within the RAA.

Shown here is a fluoroscopic image (continuous X-ray) of a tined dislodgement of a tined fixation lead placed in the right atrial appendage (RAA). During placement, the lead can be easily removed and replaced elsewhere by applying retraction force. Clinical dislodgement rarely occurs, for within hours to days this lead will become fibrosed within the RAA. The inset on the lower right shows the simultaneous videoscopic view.

Shown here is a videoscopic view of an active fixation, fixed helix, lead being placed between the tricuspid valve annulus and the right atrial appendage (RAA). A steerable delivery catheter is used to place the lead in the proper location; the lead is delivered through the catheter to the myocardium and then fixed into the myocardium. The catheter is then retracted, and a lead is placed near the coronary sinus (CS).

Shown here is a videoscopic view of an active fixation, fixed helix, lead being placed between the tricuspid valve annulus and the right atrial appendage (RAA). A steerable delivery catheter is used to place the lead in the proper location; the lead is delivered through the catheter to the myocardium and then fixed into the myocardium (close-up view of the helix engaging the myocardium). The catheter is then retracted, and a lead is placed near the septal wall within the Triangle of Koch.

Shown here is a videoscopic view of an active fixation, fixed helix, lead being placed in the apex of the right ventricle (RVA). A steerable delivery catheter is used to place the lead in the proper location; the lead is delivered through the catheter to the myocardium and then fixed into the myocardium. Also shown are lead placements within the right atrium.

Shown here is a close-up videoscopic view of an active fixation lead (this device has a fixed helix). The lead is being placed in the apex of the right ventricle (RVA). A steerable delivery catheter is used to place the lead in the proper location; the lead is delivered through the catheter to the myocardium and then fixed.

Shown here is a videoscopic view of a lead being fixed within the pectinate muscle bands of the right atrial appendage (RAA). A fixed-shape (J) delivery catheter is used to place the lead in the proper location in the RAA. The lead is then rotated within the catheter to engage the helix (lead tip) into the myocardium. Next the catheter is retracted and the lead remains fixed.

Pacing from left heart sites has recently been shown to improve cardiac function in patients with advanced heart failure, dilated cardiomyopathy, and ventricular conduction abnormalities. The coronary sinus (CS) vasculature was found to be adequate in most patients (83%) for placement of a LV pacing lead into the posterior-lateral or lateral positions for cardiac resynchronization. Increased tortuosity or lack of an adequate lateral vein resulted in alternative left-sided lead placement in 17% of patients.

Results suggest that LV and RV lead positions are both important in the efficacy of cardiac resynchronization in heart failure patients.

Shown here is a videoscopic view of a left heart lead placed in the great cardiac vein via a delivered catheter positioned within the coronary sinus.

Pacing from left heart sites has recently been shown to improve cardiac function in patients with advanced heart failure, dilated cardiomyopathy, and ventricular conduction abnormalities. The coronary sinus (CS) vasculature was found to be adequate in most patients (83%) for placement of a LV pacing lead into the posterior-lateral or lateral positions for cardiac resynchronization. Increased tortuosity or lack of an adequate lateral vein resulted in alternative left-sided lead placement in 17% of patients.

Results suggest that LV and RV lead positions are both important in the efficacy of cardiac resynchronization in heart failure patients. Randomized control studies may provide further information regarding optimization of lead position.

Shown here is a fluoroscopic view (continuous X-ray) of a left heart lead placed in the great cardiac vein via a delivered catheter in the coronary sinus. Before lead advancement, a contrast is injected retrograde into the cardiac venous system (venogram). The simultaneous picture-in-picture videoscopic view (lower right) also shows this implant procedure.

Pacing from left heart sites has recently been shown to improve cardiac function in patients with advanced heart failure, dilated cardiomyopathy, and ventricular conduction abnormalities. Results suggest that LV and RV lead positions are both important in the efficacy of cardiac resynchronization in heart failure patients.

Shown here is a videoscopic view within the cardiac vein of a lead being manipulated to sub-select a branch of choice.

Pacing from left heart sites has recently been shown to improve cardiac function in patients with advanced heart failure, dilated cardiomyopathy, and ventricular conduction abnormalities. The coronary sinus (CS) vasculature was found to be adequate in most patients (83%) for placement of a LV pacing lead into the posterior-lateral or lateral positions for cardiac resynchronization. Increased tortuosity or lack of an adequate lateral vein resulted in alternative left-sided lead placement in 17% of patients.

Results suggest that LV and RV lead positions are both important in the efficacy of cardiac resynchronization in heart failure patients. Randomized control studies may provide further information regarding optimization of lead position.

Shown here is a fluoroscopic view (continuous X-ray) within the cardiac vein of a lead being manipulated to sub-select a branch of choice. The simultaneous picture-in-picture videoscopic view (lower right) also shows this implant procedure.

Shown here is a videoscopic view of a passive fixation (tined) lead being placed into the right atrial appendage (RAA). A stylet is used to orient the lead in the desired location in the RAA.

Shown here is a videoscopic view of a passive fixation (tined) lead being placed into the right ventricular apex (RVA). A stylet is used to orient the lead in the desired location in the RVA. One can see how the tines become engaged into the tissue; this lead will eventually become fibrosed into the heart.

Shown here is a videoscopic view of a tined fixation lead momentarily tangled in the chordae tendinae of the tricuspid valve.

Shown here is a fluoroscopic view (continuous X-ray) of a tined fixation lead momentarily tangled in the chordae tendinae of the tricuspid valve. The inset on the lower right shows the simultaneous videoscopic view.

The right atrial appendage (RAA) is the traditional implant site for atrial leads because of its trabeculated nature. Shown here is the placement of a passive fixation or tined lead within the RAA.

Shown here is a fluoroscopic image (continuous X-ray) of a tined fixation lead placed in the right atrial appendage (RAA). The large dark structure on seen on fluoro is the video camera entering the right atrium via access through the pulmonary artery and passing retrograde through the tricuspid valve. The inset on the lower right shows the simultaneous videoscopic view of the implant.

Since the first use of the transvenous route for cardiac pacing by Furman and Schwedel in 1959, this site has been used for the vast majority of permanent pacemaker implants. Although the site is relatively easy to access and the rate of dislodgements is low, the RV apex site does not necessarily provide the best acute or chronic hemodynamic effect, a favorable effect on remodeling, long-term survival, or quality of life.

Shown here is the videoscopic view of the placement of a tined lead within the apex of the right ventricle; the lead was prolapsed through the tricuspid valve and the lead tip positioned within the apex.

Shown here is the fluoroscopic view (continuous X-ray) of the placement of a tined lead within the apex of the right ventricle; the lead was prolapsed through the tricuspid valve and the lead tip positioned within the apex. The inset on the lower right shows the simultaneous videoscopic view.

Pacing the His bundle or near the His bundle may provide for more physiological pacing of the heart, by activating the normal ventricular conduction system. This allows a more rapid and normal activation of the ventricles, i.e., provided that the distal conduction system (right and left bundle branches) is normal. Transvenous His stimulation was demonstrated in canines (1969) and humans (1970) using multipolar catheters positioned at the AV junction above the septal leaflet of the tricuspid valve.

Shown here is a videoscopic view of a lead positioned and implanted to activate the His Bundle.

Pacing the His bundle or near the His bundle may provide for more physiological pacing of the heart, by activating the normal ventricular conduction system. This allows a more rapid and normal activation of the ventricles, i.e., provided that the distal conduction system (right and left bundle branches) is normal. Transvenous His stimulation was demonstrated in canines (1969) and humans (1970) using multipolar catheters positioned at the AV junction above the septal leaflet of the tricuspid valve.

Shown here is a fluoroscopic view (continuous X-ray) of a lead positioned and implanted to activate the His Bundle; the inset (lower left) shows the videoscopic view.

One method to achieve synchronous depolarization of both atria without concern for inter-atrial conduction time is atrial septal pacing. It is proposed that this pacing system allows an optimal timing of the left-sided atrioventricular delay.

Shown here is a videoscopic view of a lead implant into the right atrial septum.

One method to achieve synchronous depolarization of both atria without concern for inter-atrial conduction time is atrial septal pacing. It is proposed that this pacing system allows an optimal timing of the left-sided atrioventricular delay.

Shown here is a fluoroscopic view (continuous X-ray) of a lead implant into the right atrial septum; the inset (lower left) shows the videoscopic image.

Right ventricular septal pacing has been found to produce a more synchronous ventricular activation than right ventricular apex pacing. Although pacing at both sites appears to impair left ventricular function, these effects are less marked with right ventricular septal pacing, suggesting a benefit in the more physiological right ventricular septal pacing mode.

Shown here is a videoscopic view of an active fixation lead crossing the tricuspid valve from the superior vena cava (SVC). Then the lead is passed up the RVOT and eventually placed in the RV high septum. One can see a close-up of the helix of the active fixation lead being deployed and engaging tissue.

Right ventricular septal pacing has been found to produce a more synchronous ventricular activation than right ventricular apex pacing. Although pacing at both sites appears to impair left ventricular function, these effects are less marked with right ventricular septal pacing, suggesting a benefit in the more physiological right ventricular septal pacing mode.

Shown here is the fluoroscopic view (continuous X-ray) of an active fixation lead crossing the tricuspid valve from the superior vena cava (SVC). Then the lead is passed up the RVOT and eventually placed in the RV high septum. The simultaneous picture-in-picture videoscopic view (lower right) also shows this implant procedure.

Right ventricular septal pacing has been found to produce a more synchronous ventricular activation than right ventricular apex pacing. Although pacing at both sites appears to impair left ventricular function, these effects are less marked with right ventricular septal pacing, suggesting a benefit in the more physiological right ventricular septal pacing mode.

Shown here is a videoscopic view of an active fixation lead crossing the tricuspid valve from the superior vena cava (SVC). Then the lead is passed up the RVOT and eventually placed in the RV low septum.

Right ventricular septal pacing has been found to produce a more synchronous ventricular activation than right ventricular apex pacing. Although pacing at both sites appears to impair left ventricular function, these effects are less marked with right ventricular septal pacing, suggesting a benefit in the more physiological right ventricular septal pacing mode.

Shown here is the fluoroscopic view (continuous X-ray) of an active fixation lead crossing the tricuspid valve from the superior vena cava (SVC). Then the lead is passed up the RVOT and eventually placed in the RV low septum. The simultaneous picture-in-picture videoscopic view (lower right) also shows this implant procedure.

Placement of a lead within the right ventricular outflow tract (RVOT) has shown positive benefits over those positioned in the right ventricular apex.

Shown here is a videoscopic view of an active fixation lead crossing the tricuspid valve from the superior vena cava (SVC). Then the lead is passed up the RVOT and eventually placed (helix engaged within the myocardium) in the RVOT.

Placement of a lead within the right ventricular outflow tract (RVOT) has shown positive benefits over those positioned in the right ventricular apex.

Shown here is a fluoroscopic view (continuous X-ray) of an active fixation lead crossing the tricuspid valve from the superior vena cava (SVC). Then the lead is passed up the RVOT and eventually placed (helix engaged within the myocardium) in the RVOT. The simultaneous picture-in-picture videoscopic view (lower left) also shows this implant procedure.

Shown here is an external view of an active fixation epicardial lead sewn onto the lateral wall of the left ventricle (LV).

Shown here is an external view of an epicardial lead sewn onto the lateral wall of the left ventricle (LV).

Shown here is an external view of a pair of epicardial leads with a helix that was scewed into the lateral wall of the left ventricle (LV).

Shown here is a videoscopic view of a lead being fixed within the septum of the right atrium (RA), to activate the Bundle of His (the tricuspid valve can be viewed below to the right). A fixed-shape delivery catheter is used to place the lead in the proper location in the RAA. The lead is then rotated within the catheter to engage the helix (lead tip) into the myocardium. The catheter is then retracted and the lead remains fixed.

Shown here is a close-up videoscopic view of a lead being fixed within the septum of the right atrium (RA), to activate the Bundle of His (the tricuspid valve can be viewed below to the right). A fixed-shape delivery catheter is used to place the lead in the proper location in the RAA. The lead is then rotated within the catheter to engage the helix (lead tip) into the myocardium. The catheter is then retracted and the lead remains fixed.

Shown here is a close-up videoscopic view of an active fixation lead being placed in the septal wall for the right ventricle (RV); the moderator band can be viewed behind the placement. The lead is being placed into the septum using a fixed-shape catheter. The lead is then rotated within the catheter to engage the helix (lead tip) into the myocardium. The catheter is then retracted and the lead remains fixed.

Shown here is a videoscopic view of a lead placement near the bundle of His in the right atrium (RA). A fixed-shape delivery catheter is used to place the lead in the proper location, then the lead is delivered through the catheter to the myocardium. The lead is then rotated within the catheter to fix the helix (lead tip) into the myocardium (close-up view of helix engaging the myocardium). The catheter is then retracted, and a lead body is placed near the septal wall.

Shown here is an external view of a guidewire and lead being advanced into the left anterior descending vein, and then a sub-branch is selected for final placement.

Shown here is an external view of a guidewire and lead being advanced into the left anterior descending vein. The lead itself is then used to identify a sub-branch for final placement.

Shown here is an external view of a guidewire and lead being advanced into the left anterior descending vein, and then a sub-branch is selected for final placement. The guidewire is extended and retracted and the lead advanced until the desired location is identified. This is an active fixation lead, which is fixed into the vein by deploying more proximal lobes which expand in the vessel.

Shown here is an external view of a guidewire and lead being advanced into the left anterior descending vein, and then a sub-branch is selected for final placement. The wire is advanced and retracted until desired branches are found. This lead has distal and more proximal electrodes.

The right ventricular apex is the traditional location for placement of the primary intracardiac electrode to optimize the defibrillation vector, for ease of placement with both passive and active fixation leads and for proven performance as a pacing/sensing site. This lead often incorporates a second electrode positioned in the superior vena cava.

Shown here is a videoscopic view of an active fixation defibrillation lead placed in the apex of the right ventricle; the lead can be observed as it passes through the tricuspid valve.

The right ventricular apex is the traditional location for placement of the primary intracardiac electrode to optimize the defibrillation vector, for ease of placement with both passive and active fixation leads and for proven performance as a pacing/sensing site. This lead often incorporates a second electrode positioned in the superior vena cava.

Shown here is a fluoroscopic view of an active fixation defibrillation lead placed in the right ventricle apex. The simultaneous picture-in-picture videoscopic view (lower right) also shows this implant procedure.

Shown here is a videoscopic view of an active fixation defibrillation lead being placed into the right ventricular apex (RVA). A stylet is used to orient the lead in the desired location in the RVA. Once there, the helix is extended by rotating the proximal pin of the lead which, in turn, extends the helix out of the tip of the lead body and into the tissue. One can see the distal coil of the defibrillation lead.

Shown here is a close-up videoscopic view of an active fixation defibrillation lead being placed into the right ventricular apex (RVA). A stylet is used to orient the lead in the desired location in the RVA. Once there, the helix is extended by rotating the proximal pin of the lead which, in turn, extends the helix out of the tip of the lead body and into the tissue. One can see the coil of the defibrillation lead.

Shown here is a videoscopic view of a passive fixation defibrillation lead being placed into the right ventricular apex (RVA). A stylet is used to orient the lead in the desired location in the RVA. One can see how the tines become engaged into the tissue; this lead will eventually become fibrosed into the heart. Also, one can observe the distal coil of the defibrillation lead.

The right ventricular apex is the traditional location for placement of the primary intracardiac electrode to optimize the defibrillation vector, for ease of placement with both passive and active fixation leads and for proven performance as a pacing/sensing site. This lead often incorporates a second electrode positioned in the superior vena cava.

Shown here is a videoscopic view of a heart in fibrillation; defibrillation therapy is then administered to reinitiate a normal heart rhythm. A tined defibrillation lead can be viewed from the RV apex.

The right ventricular apex is the traditional location for placement of the primary intracardiac electrode to optimize the defibrillation vector, for ease of placement with both passive and active fixation leads and for proven performance as a pacing/sensing site. This lead often incorporates a second electrode positioned in the superior vena cava.

Shown here is a videoscopic view within a reanimated human heart in which fibrillation was induced; defibrillation therapy is then administered to reinitiate a normal heart rhythm. A tined defibrillation lead can be viewed from the RV apex.