How do they see what they're doing?

Please forgive this post if it seems too trivial, but it is something that has long puzzled me.

Looking at some of the X-ray photos in the members' gallery I am struck by how clearly I can see the PM and the leads, but I cannot make out the outline of the heart at all, let alone its different chambers. These photos are very similar to what the X-ray monitor was showing at the time of my own operation.

So if this is the best view available to the surgeon, how do they know when the leads are in right position to be anchored? Do they have something else to go by, or can they see something that I can't ?

3 Comments

Fluoroscopy

by Lavender - 2024-09-24 11:48:41

Fluoroscopy, (a special type of X-ray that will be displayed on a TV monitor), may be used to assist in testing the location of the leads. 

It's not the xray imagery you're describing. A fluoroscope allows a surgeon to see the internal structure and function of a patient, so that the pumping action of the heart can be watched.

It's sometimes difficult

by crustyg - 2024-09-24 12:45:54

Lavender has explained that they have a real-time X-ray image (very low dose X-ray source from above to below your chest, with an image-intensifier to make the view usable), which does show the heart outline as well as a normal PA view.  Once you learn where the edges of the various things inside the chest appear you can see a lot.  You *may* not be looking far enough out to see the heart outline...

Having said that, there are some real challenges in getting leads into the correct position: knowledge of anatomy, experience/skill by the operator, and built-in curves to the leads to help them get into the correct location (e.g. R atrial appendage).

Also, it's not possible to determine with any certainty using the Anterior/Posterior (==top down) fluoroscopy view whether the RV lead has been attached to the thick septum muscle that separates RV from LV, or the much thinner anterior wall of the RV (we've had a few contributors here where that has happened).  This is why a lateral Chest X-ray should be done immediately after lead placement to prove that the RV lead is attached at the correct location.

There is a lot of experience and skill required to put in a CRT lead, given the very sharp corner and small opening that has to be negotiated to put the lead into the correct location.

For ablations there are a couple of internal mapping tools that really help the operator identify the internal electrical architecture of the heart - which is reassuring when you think what's going to happen to a little bit of the inside of your heart when the operator presses the ablate pedal!  Real-time X-ray for physical placement, internal mapping for electrical placement.

Skill + technology - it really can seem like magic.

Thanks both

by Repero - 2024-09-24 13:25:06

Thank you both for your input. Very interesting.

As suggested by crustyg, I think my main problem is not knowing what to look for on those images. Obviously training and experience enable one to get a lot more out of them.

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