European Journal of Radiology 84 (2015) 499508

Contents lists available at ScienceDirect

European Journal of Radiology

journal homepage: www.elsevier.com/locate/ejrad

Review

Pacemakers and implantable cardioverter debrillators, unknown to

chest radiography: Review, complications and systematic reading
Salvador Pascual Alandete Germn , Santiago Isarria Vidal,

Mara Luisa Domingo Montanana,

Esperanza De la va Ora, Jos Vilar Samper
Department of Radiology, Hospital Doctor Peset, Av/Gaspar Aguilar 90, Valencia 46017, Spain

a r t i c l e

i n f o

Article history:
Received 22 October 2014
Received in revised form 3 December 2014
Accepted 6 December 2014
Keywords:
Pacemaker
Cardiac device
Implantable cardio-debrillators
Complications
Cardiovascular imaging

a b s t r a c t
Chest X-ray is the imaging technique of choice for an initial study of pacemakers and implantable cardiodebrillators (ICD). Radiologists have an important role in the evaluation of its initial placement and in
the assessment during its follow-up. For this reason, it is necessary to know not only the different existing
devices and its components but also the reasons of malfunction or possible complications.
The purpose of this article is to do a systematic review of the different types of pacemakers and ICD.
We review their usual radiological appearances, the possible complications which might take place and
its causes of malfunctioning.
2014 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
There are two types of cardiac conduction devices: pacemakers
and implantable cardio-debrillators (ICDs).
Pacemakers, in general, are indicated for heart rhythm disorders
with abnormally low heart rate. The two main causes are sick sinus
syndrome or AV block.
Different types of pacemakers exist, the simplest are singlechamber pacemakers which send electrical impulses to one
chamber (atrium or ventricle) of the heart, while dual-chamber
pacemakers have wires placed in right atrium and right ventricle.
Biventricular pacemakers are used to cardiac resynchronization.
The electrodes are situated in right ventricle and left ventricle by
way of the coronary sinus [1].
The VDD pacemaker is the only exception to this scheme. It is a
model that, by a single electrode detects in both chambers (atrium
and ventricle) but only stimulates the ventricle.
There are now a new generation of three-chamber pacemakers
that add the ability to stimulate the left ventricle of the heart. They
are indicated in patients with severe heart failure.

Corresponding author. Tel.: +34 680343463; fax: +96 386 25 01.

E-mail addresses: salaiger@gmail.com (S.P. Alandete Germn), isarria@comv.es

(S. Isarria Vidal), domingo.luimon@gmail.com (M.L. Domingo Montanana),

esviao82@gmail.com (E. De la va Ora), vilarsamper@gmail.com (J. Vilar Samper).
http://dx.doi.org/10.1016/j.ejrad.2014.12.011
0720-048X/ 2014 Elsevier Ireland Ltd. All rights reserved.

An ICD is an electronic device capable of generating a large

amount of energy in order to debrillate the heart. It is used to
treat ventricular arrhythmias and prevent sudden death [2].
The chest X-ray is the elective technique in the initial study of a
cardiac device and radiologists participate in the assessment of its
insertion and its subsequent follow-up. This is why it is necessary
to be familiarized with the various devices and their components
in use today, as well as with their normal radiological appearance
[3].
Our objective in this work is to offer a systematic review of
the different types of existing pacemakers and implantable cardiodefribillators (ICD), establishing a diagnostic algorithm to evaluate
the causes of malfunction and the complications that may arise
(Table 1) [4].
For a correct evaluation we advise that the following points
should be read and the steps described hereunder should be
adhered to: [5]
(A) Immediate complications after the insertion of the device.
(B) Control and follow up of the device.
2. Immediate complications after the insertion of the
device
The standard procedure following the insertion of pacemakers
involves an immediate uoroscopic evaluation of the electrodes

500

S.P. Alandete Germn et al. / European Journal of Radiology 84 (2015) 499508

Fig. 1. Normal chest X-ray (a) and enlarged image (b) with the tip of the electrode beyond the cardiac silhouette and below the diaphragm. CT axial (c) and coronal (d) images
showing cardiac perforation by right ventricle electrode. The tip of the electrode is close to the diaphragm stimulating it.

positioning [6], followed by a chest X-ray 24 h after its insertion

[7]. If there are no complications, the patient is discharged and
re-evaluated 4 to 6 weeks after with an electrocardiogram and a
pacemaker test. A chest X-ray is carried out only if any abnormalities appear in the said check-ups [8].
Early complications that may arise in the initial chest X-ray are:
2.1. Myocardial perforation
Myocardial perforation, a potentially serious complication, is
relatively rare occurring in less than 1% of cases [9].
A chest X-ray may show up an inappropriate position of the ventricular electrode more caudal than usual (under the diaphragm)
(Fig. 1). In cases of doubt, a CT scan can help in determining the
electrodes place exactly.
Moreover, in these cases there is a possibility of pleural or pericardial effusion (pericarditis), cardiac tamponade or extracardial
stimulation (diaphragm, intercostal or abdominal muscles) (Fig. 2).

Table 1
Cardiac devices interpretation: Systematic approach.
Systematic approach
Immediate complications
Myocardial perforation
Pneumothorax, hemothorax
Control and follow-up
Differentiate between pacemaker or ICD
Identify the companys logo
Review the pulse generator site
Inspect the connector block
Check the full length of the electrode
Lead position
Other complications

The use of active xation (later explained) and old-age are associated with a greater incidence of cardiac perforation. Paradoxically
perforation is due mainly to atrial leads [10].
2.2. Pneumothorax, hemothorax
Pneumothorax may appear during the procedure or 48 h after
insertion [11].
This complication is quite rare (12%) and it is associated with
the experience of the person performing the procedure and the
difculty of venopuncture of the subclavian vein (Fig. 3).
If the subclavian artery is lacerated, a soft tissue hematoma may
appear or in more severe cases a hemothorax may be occurred.
3. Control and follow up of the device
3.1. Differentiate between a pacemaker and an implantable
debrillator identify the different models
Cardiac devices are generally composed by an impulse generator
and one or more electrodes [12].
Impulse generators have a titanium casing containing a lithium
battery which is normally implanted into a subcutaneous pocket
in the pectoralis major muscle usually placed in the patients arm
opposite to the dominant side for convenience. However another
possible location, particularly suitable in pediatric patients, is the
abdomen (Fig. 4).
The electrodes are metallic conductors with a silicone or
polyurethane insulation layer, they are normally inserted into the
cephalic or subclavian vein. The xing mechanism for the electrodes may be passive or active. In the passive mode, conical
structures are attached at the end and these are anchored to the
cardiac trabeculae. This method takes between 6 weeks to 3 months

S.P. Alandete Germn et al. / European Journal of Radiology 84 (2015) 499508

501

Fig. 2. Chest X-ray before (a) and after (b) pacemaker placement shows increased cardiac silhouette and right pleural effusion. Pericardial effusion due to cardiac perforation
is seen in axial (c) and coronal (d) CT images. Also note the left sided superior vena cava.

for scar tissue to form. A correct insertion is important as movement

may occur in this period. In the active xing mode, a helical structure at one end penetrates the myocardium. Obviously in the active
xing mode there is a comparatively greater risk of perforation than
in the passive mode (Fig. 5).
ICDs are used as primary and secondary preventions for ventricular tachycardia in patients at risk of sudden death. ICDs are
different to pacemakers mainly since they contain two radiopaque
shock-coils that deliver a considerable amount of energy, administrating impulses to the myocardium in cases of brillation. These

shock-coils appear as thick radio-opaque bands and are located in

the junction of the brachiocephalic vein with the superior vena
cava and in the right ventricle (Fig. 6) [13]. Previously ICDs had
larger sizes than pacemakers, although in more recent models this
difference is not so great.
3.2. Identify the companys logo
The companies that manufacture these cardiac devices produce
a specic programmer to test each PM or ICD.
Although the patient presents the identity sheet of the inserted
cardiac device, radiologists will be able to easily identify the
companys logo and hence assist the clinician in selecting the appropriate programmer. The logo is situated on the casing of the device,
quite close to the electrode connections [14].
The increased use of magnetic resonance imaging (MRI) and the
incompatible nature of carrying out this test on patients with PM
or ICD, has encouraged different manufacturers to produce devices
which minimize electromagnetic interferences and enable its use.
These devices compatible with MRI have identiable radiological characteristics, for example it is frequent that a radio-opaque
marker is inserted at the proximal end of the electrode, close to the
casing. Sometimes there is also a distinguishing feature in the logo
itself that denotes that it is compatible for MRI (Fig. 7) [15].
3.3. Review the correct positioning of the generator inside the
pocket

Fig. 3. Chest X-ray showing left pneumothorax (arrow) after placement of a leftsided permanent dual chamber pacemaker.

The impulse generator is preferably implanted within a subcutaneous pocket in front of the pectoralis major muscle (prepectoral
fascia), more often at the left infraclavicular site. An alternative
place for the left handed is the right infraclavicular site or for the
women the inframammary site for cosmetic reasons.

502

S.P. Alandete Germn et al. / European Journal of Radiology 84 (2015) 499508

Fig. 4. Normal components of a pacemaker. (a) Chest X-ray shows the basic components (generator and leads), (b) Lead is connected to generator through a header which
holds one or more connection ports. Manufacturer logo is also appreciated (see Fig. 7).

Fig. 5. Enlarged images of electrodes. (a) Passive xing with conical structure at the tip, (b) Active xing by screw tip to be placed in myocardium.

Twiddlers syndrome consists of a rotation of the pacemakers

casing along its longitudinal axis [16], due to the patients own
manipulation. As resulting the leads get twisted around the casing and their ends are displaced. The prevalence of this syndrome
is 0.07%; it is more frequent in obese women and in the rst year
post-insertion. Other predisposing factors are mental retardation,
dementia and a subcutaneous pocket that is too big (Fig. 8).
When the impulse generator rotates along its transversal axis, it
is called Reels syndrome, a variant of Twiddlers syndrome (Fig. 9)
[17].
Other complications that may appear include a hematoma at
the insertion site in patients treated with anticoagulants and the
infection of the pocket, which is manifested by pain, swelling and
inammation of the soft tissues. In severe cases we may observe
the presence of air-uid level.

3.4. Inspect the electrodes port insertion sites connecting to the

generator
Fig. 6. Shock coil that surrounds right ventricular (RV) lead in an ICD. In some ICD,
another shock coil in superior vena cava (SVC) is present as in this case, although
it might not be present in all systems. Nevertheless pacemakers do not have shock
coils.

The electrodes have at their most proximal portion insertion

ports to connect the lead to the generator. It is essential that

S.P. Alandete Germn et al. / European Journal of Radiology 84 (2015) 499508

503

Fig. 7. Examples of manufacturer logos: (a) Biotronik, (b) St. Jude Medical, (c) Boston Scientic.
MRI compatible devices: (d) Curvilinear line above logo (circle) and metal densities coiling around leads (square), (e) MRI electrode radiopaque markers consist in three rings
in the proximal portion of the lead, close to the header, (f) MRI logo that species that this device is compatible.

electrode should slightly protrude over the connector for the

device to function correctly; otherwise, the pacemaker will
not function correctly and the electrode will have to be repositioned (Fig. 10) [18]. Radiologist should be aware of this
aspect.
3.5. Check the full length of the electrodes to rule out any damage
or breakages

Fig. 8. Twiddlers syndrome: Chest X-ray reveals proximal portion of the electrode
rolled along the pacemakers long axis, due to the rotation of the generator on its
longitudinal axis.

It is of utmost importance to check the full length of the lead as

we may nd incorrect positions and disturbances.
Leads may follow an abnormal course or have their ends
in incorrect positions due to normal variants as in the case
of a left superior vena cava or congenital cardiac conditions
(patent foramen oval, transposition of great arteries) (Fig. 11)
[19].
Lead breakages have an incidence among 14% and may be
observed at any point of their pathway. Of interest is that the most
common breakage points are at their connection point with the

Fig. 9. Reels syndrome. (a) Normoplaced pacemaker, (b) Chest X-ray shows dislodgement of the right atrial and ventricular lead. Both leads are wrapped around the
pacemaker generator due to the rotation of the generator on its transversal axis.

504

S.P. Alandete Germn et al. / European Journal of Radiology 84 (2015) 499508

Fig. 10. (a) Properly placed lead pins will extend beyond connector (square), (b) Appearance of lead that has completely backed out from terminal (circle)
Source: With permission of [9].

generator or just at the entry of the subclavian vein, where it is

compressed between the clavicle and the rst rib. In this latter case,
it is known as clavicle crush or subclavian crush. In cases of fracture, there is a discontinuity between the two extremes, however,
prior to this, the electrode appears to be thinner and usually still
functions (Fig. 12).
The electrodes should follow a straight pathway and avoid
any loops from forming as they can lead to the appearance
of cardiac arrhythmia if they are located within a cardiac

cavity, as well as migration and translocation of the electrode tip

(Fig. 13).
In pediatrics, a redundant electrode is preferred as it
allows for the childs growth without him or her causing any
dislocations and thereby reducing the number of check-ups necessary.
There are patients who may need to have the generator or electrode replaced for different reasons such as infection, depletion of
the battery or malfunction.

Fig. 11. Aberrant lead course. (a) AP chest radiograph illustrates leads that course through an unknown persistent left superior vena cava. The later venography conrms
this nding. (b) Patient with an interauricular communication, the electrode passes through communication and it is placed in the left auricle, more posterior in the lateral
projection.

S.P. Alandete Germn et al. / European Journal of Radiology 84 (2015) 499508

505

Fig. 12. Examples of lead fracture: (a) Magnied chest x-ray with an abandoned electrode due to a thinning of the lead (incomplete fracture) in the common location between
the clavicle and rst rib (rib-clavicle crush). (b) Another common breakage site at their connection point with the generator.

Fig. 13. PA (a) and lateral (b) chest X-ray shows ventricular lead looped inside the ventricle.

3.6. Verify that the electrode head is correctly positioned and that
it does not present a different state with respect to previous studies
3.6.1. Right atrial (RA) electrode
The auricular electrode is more frequently positioned at the
right atrial appendage but there is increasing interest in its
septal positioning in order to minimize delay in intra-atrial
conduction that occurs when it is located in the appendage
[20].
In the posterioranterior (PA) projection, a slightly medial
trajectory is observed, whereas in the lateral case, its position
is anterior forming a J with an angle less than 90 (Fig. 15)
[21].

Fig. 14. In cases of marked brosis it is not possible to remove the lead and therefore
it is abandoned. A new contralateral device is placed in the left site.

The presence of brous tissue around the electrodes might damage the vessel walls and in these cases it may not be possible
or safe to remove them. Such leads are abandoned and remain
visible in successive follow-ups but pose no pathological signicance (Fig. 14).

3.6.2. Right ventricle (RV) electrode

The electrode is positioned at the apex of the right ventricle.
In X-rays it appears in the PA projection with the tip pointing
down between the left perimeter of the heart and the cardiac apex.
In the case of lateral projection, when the electrode is correctly
positioned, the lead should smoothly curve along the length of the
lateral wall of the RA, crossing the tricuspid valve and reaching the
apex (Fig. 15).
Even though this most commonly occurs in the apex, the end
may be positioned elsewhere such as in the exit tract of the RV or
in the interventricular septum [22,23].

506

S.P. Alandete Germn et al. / European Journal of Radiology 84 (2015) 499508

Fig. 15. Normal cardiac anatomy. Posteroanterior (a) and lateral (b) chest X-ray, the correct placement of the atrial lead is in the atrial appendage (green dotted circle) and
the right ventricle lead is in the apex of right ventricle (RV) (blue dotted circle).

Fig. 16. Normal cardiac veins anatomy: Illustration in posteroanterior chest X-ray (a) and lateral (b) shows anterior interventricular (AIV) and posterolateral (PLV) veins
draining into the great cardiac vein (GCV). Middle vein (VM) joins to the coronary sinus. (c) Lateral chest X-ray is divided in three segments (anterior, posterior and lateral)
to determine the position of the left ventricle (LV) electrode.

3.6.3. Electrode in the coronary sinus (left ventricle electrode)

With the advent of cardiac resynchronization pacemakers, the
placement of electrodes in the coronary sinus has become a normal
practice.
First of all, it is important to be familiarized with the coronary
venous system. For a correct positioning of an electrode in the coronary sinus, its tip needs to be at the posterolateral coronary vein,

anterior interventricular vein or the middle cardiac vein (Fig. 16)

[24].
In an AP projection, it is difcult to differentiate a RV catheter
from a left one. To differentiate them, we can make oblique projections; in the ROA (right oblique anterior) the cushion of fatty tissue
denes the AV separation plane. Parallel to this plane, the coronary
sinus is located and it is here where the LV electrode should be

Fig. 17. Posteroanterior (a) and lateral (b) chest X-ray show displacement of atrial lead (circle).

S.P. Alandete Germn et al. / European Journal of Radiology 84 (2015) 499508

507

Fig. 18. Posteroanterior (a) and lateral (b) chest X-ray show displacement of left ventricle lead (circle).

Fig. 19. Posteroanterior (a) and lateral (b) chest X-ray show an abnormally positioned right ventricular lead in the right ventricular outow tract.

Fig. 20. Septic emboli due to endocarditis in a pacemaker carrier. (a) Posteroanterior chest X-ray with diffuse bilateral nodular densities (arrow) in different stages of
cavitation. (b) Echocardiography demonstrates large mitral valve vegetation (arrow). (c) Axial CT shows numerous variable sized cavitating nodules with bubbly lucencies
representing septic emboli in both lungs (arrow).

positioned until it reaches a heart vein; on the other hand if it is a

RV electrode, its route will be perpendicular to this plane, moving
in the direction of the ventricular apex [25].
In clinical practice lateral projections are more frequent than
oblique projections; In this case the RV electrode is located more
anterior while the position of the coronary sinus electrode is
more posterior in the cardiac silhouette. With the intention of

determining the position of the left ventricle (LV) electrode, the

cardiac silhouette in the lateral chest X-ray is divided into three
segments (anterior, posterior and lateral) (Fig. 16).
Although these positions described are the optimal ones, in
some cases a slightly incorrect or small variation in optimal positioning is admissible if the potentials obtained are good. This is why
it is useful during the follow up to carry out a comparative study

508

S.P. Alandete Germn et al. / European Journal of Radiology 84 (2015) 499508

References

Fig. 21. Venous thrombosis. (a) Venography shows thrombi present in the left subclavian vein (circle).

with previous X-rays, so we can suspect an electrodes dislocation

or migration when we observe an anomalous position of the lead
or a change in its position (Figs. 1719) [26].
3.7. Ruling out other associated complications
Apart from the complications discussed in previous sections,
other ones may arise during the follow up of these devices.
Chronic complications such as endocarditis or vein thrombosis may
develop.
3.7.1. Endocarditis
Infections may be local or systemic, giving rise to sepsis or endocarditis.
The most commonly isolated organisms are Staphylococcus and
Streptococcus epidermidis. An attempt to remove the infected stimulation wire may lead to its fragmentation (Fig. 20) [27].
3.7.2. Vein thrombosis
Vein thrombosis may appear in 3050% of patients who have
had pacemakers inserted, either at an early or late stage. Vein
thrombosis after the insertion of a pacemaker or ICD rarely causes
symptoms in early stages. Patients can remain asymptomatic due
to collateral vein development (Fig. 21).
The predisposing factors are: presence of multiple pacemaker
leads, hormonal therapy, history of previous thrombosis and the
previous presence of pacemakers [28].
4. Conclusions
Radiologists have a specic and important role in the management of pacemaker and implantable cardio-debrillators. In this
way, we must be familiar with their basic characteristics and should
be aware of the causes of malfunction and the possible complications that may arise.
Conict of interest
We wish to conrm that there are no known conicts of interest
associated with this publication and there has been no signicant
nancial support for this work that could have inuenced its outcome.

[1] Fred M, Kusumoto MD, Nora F, Goldschlager MD. Cardiac Pacing for the Clinician. Springer Science Business Media; 2008.
[2] Serge Barold S, Roland X, Stroobandt, Sinnaeve AF. Cardiac Pacemakers and
Resynchronization Step-by-Step: An Illustrated Guide. 2nd Edition WileyBlackwell; 2010.
[3] Bonow RO, Mann DL, Zipes DP, Libby P. Braunwalds Heart Disease: A Textbook
of Cardiovascular Medicine. Elsevier Health Sciences; 2013. p. 75379.
[4] David L, Hayes MD, Samuel J, Asirvatham MD, Paul A, Friedman MD. Cardiac
Pacing, Debrillation and Resynchronization: A Clinical Approach. WileyBlackwell; 2013. p. 55390.
[5] Ellenbogen KA, Kay GN, Lau CP, Wilkoff BL, editors. Clinical cardiac pacing,
debrillation, and resynchronization therapy. Philadelphia: Saunders Elsevier;
2007. p. 91230.
[6] Roberts PR. Follow up and optimization of cardiac pacing. Heart
2005;91(September (9)):122934.
[7] Grier D, Cook PG, Hartnell GG. Chest radiographs after permanent pacing. Are
they really necessary? Clin Radiol 1990;42:2449.
[8] Borek PP, Wilkoff BL. Pacemaker and ICD leads: strategies for long-term management. J Interv Card Electrophysiol 2008;23:5972.
[9] Aguilera AL, Volokhina YV, Fisher KL. Radiography of cardiac conduction
devices: a comprehensive review. RadioGraphics 2011;31:166982.
[10] Lanzman RS, Winter J, Blondin D, Frst G, Miese FR, Abbara S, et al. Where does
it lead? Imaging features of cardiovascular implantable electronic devices on
chest radiograph and CT. Korean J Radiol 2011;12(5):6119.
[11] Elvin Gul E, Kayrak M. Common Pacemaker Problems: Lead and Pocket Complications, Modern Pacemakers - Present and Future. Intech; 2011. Available from:
http://www.intechopen.com/books/modern-pacemakers-present-and-future/
commonpacemaker-problems-lead-and-pocket-complications
[12] Bejvan SM, Ephron JH, Takasugi JE, Godwin JD, Bardy GH. Imaging of cardiac
pacemakers. AJR Am J Roentgenol 1997;169(5):13719.
[13] Costelloe CM, Murphy WA, Gladish GW, Rozner MA. Radiography of pacemakers and implantable cardioverter debrillators. AJR Am J Roentgenol
2012;199:12528.
[14] Jacob S, Shahzad M, Maheshwari R, Panaich SS, Aravindhakshan R. Cardiac Rhythm Device Identication Algorithm using X-Rays:CaRDIA-X. Heart
Rhythm 2011;8(June (6)).
[15] Medtronic. Revo MRI Surescan Pacing System, MRI Technical Manual. MedtronicWebsite Available from: http://www.medtronic.com/for-healthcareprofessionals/products-therapies/cardiac-rhythm/pacemakers/revo-mripacing-system/
[16] Benezet-Mazuecos J, Benezet J, Ortega-Carnicer J. Pacemaker Twiddler syndrome. Eur Heart J 2007;28:2000.
[17] Munawar M, Munawar DL, Basalamah F, Pambudi J. Reel syndrome: a variant
form of Twiddlers syndrome. J Arrhythmia 2011;27(4).
[18] Mellert F, Esmailzadeh B, Schneider C, Haushofer M, Schimpf R, Wolpert C,
Preusse CJ, et al. An unusual case of pacemaker failure: complete disconnection of connector block and battery of a subpectorally implanted dual chamber
pacemaker. Pacing Clin Electrophysiol 2002;25(April (4 Pt 1)):50910.
[19] Burney K, Burchard F, Papouchado M, Wilde P. Cardiac pacing systems and
implantable cardiac debrillators (ICDs): a radiological perspective of equipment, anatomy and complications. Clin Radiol 2004;59:699708.
[20] Steiner RM, Tegtmeyer CJ, Morse D, et al. The radiology of cardiac pacemakers.
RadioGraphics 1986;6(3):37399.
[21] Eagar G, Gutierrez FR, Gamache MC. Pictorial essay: radiology appearance of
implantable cardiac debrillators. AJR 1994;162:259.
[22] Takasugi JE, Godwin II, Bardy JDGH. The implantable pacemaker-cardioverter
debrillator: radiographic aspects. RadioGraphics 1994;14:127590.
[23] Kadish A, Mehra M. Heart failure devices: implantable cardioverterdebrillators and biventricular pacing therapy. Circulation 2005;111:332735.
[24] Cascade Philip N, Sneider Michael B, Koelling Todd M, Knight Bradley P. Radiographic appearance of biventricular pacing for the treatment of heart failure.
AJR Am J Roentgenol 2001;177:144750.
[25] Macas A, Gavira JJ, Alegra E, Azcrate PM, Barba J, Garca-Bolao I. Efecto de la
localizacin del electrodo ventricular izquierdo sobre los parmetros ecocardiogrcos de asincrona en pacientes sometidos a terapia de resincronizacin
cardaca. Rev Esp Cardiol 2004;57(2):13845.
[26] Khan FZ, Virdee MS, Gopalan D, Rudd J, Watson T, Fynn SP, et al. Characterization
of the suitability of coronary venous anatomy for targeting left ventricular lead
placement in patients undergoing cardiac resynchronization therapy. Europace
2009;11:14915.
[27] Kim DH, Tate J, Dresen WF, Papa Jr FC, Bloch KC, Kalams SA, Ellis CR, Baker
MT, et al. Cardiac implanted electronic device-related infective endocarditis:
clinical features, management, and outcomes of 80 consecutive patients. Pacing
Clin Electrophysiol 2014;37(August (8)):97885.
[28] Mandal S, Pande A, Mandal D, Kumar A, Sarkar A, Kahali D, et al. Permanent
pacemaker-related upper extremity deep vein thrombosis: a series of 20 cases.
Pacing Clin Electrophysiol 2012;5(October (10)):11948.