Pacemakers, LVADs & intracardiac devices
Leads, assist devices, Impella and closure devices — position, function, complications and the artefacts they create.
Numbers to remember
- A pacing lead can cause tricuspid regurgitation by impinging on or perforating a leaflet [104,6]
- With an LVAD, the aortic valve should open at least intermittently and the septum should sit midline [11]
- A mass on a lead in a febrile patient is lead endocarditis until proven otherwise [136]
Questions echo must answer
- LeadsCourse, tricuspid valve interaction, vegetations or thrombus, perforation and effusion [39,136].
- LV assist deviceInflow cannula position, septal position, aortic valve opening, RV function, AR [11].
- ImpellaPosition of the inlet below the aortic valve, away from the mitral apparatus.
- Closure devicesPosition, residual shunt, thrombus [175].
Acquisition protocol
- RV inflow and A4CFollow the lead across the tricuspid valve; colour for TR.
- LVADPLAX for septal position and aortic valve opening (M-mode); apical views for inflow cannula flow; RV function.
- PericardiumAfter lead implantation or extraction.
Diagnosis & severity
| Device | What to check |
|---|---|
| Pacing/ICD lead | Leaflet impingement, TR grade, mobile masses, perforation |
| LVAD | Septal shift, AV opening, inflow velocity, RV failure, AR |
| Impella | Inlet 3.5–4 cm below the aortic annulus, no mitral entanglement |
| Septal occluder | Stable position, no residual shunt, no thrombus |
Thresholds that change management
- Lead-related severe TR → consider lead repositioning or extraction, or tricuspid intervention [6,104].
- Lead vegetation → complete device removal with antibiotics [136].
- LVAD with septum shifted to the left and RV failing → reduce pump speed, support the RV [11].
Pitfalls & mimics
- Reverberation and side lobes from leads and prosthetic material mimic masses.
- Chiari network or Eustachian valve near a lead is not a vegetation.
- Fibrin strands on leads are common and usually benign.