Impact of lead placement site on right ventricular function: a comparative echocardiographic analysis of apical versus septal pacing in permanent pacemaker recipients

Abstract

Objectives: Permanent pacemaker (PPM) implantation is a standard intervention for bradyarrhythmias, yet the long-term hemodynamic consequences of right ventricular (RV) lead positioning remain underexplored. While apical pacing has traditionally been favored, emerging evidence suggests that septal positioning may offer more physiological activation and better preserve cardiac function. This study aimed to compare the early echocardiographic effects of apical versus septal RV lead placement on right heart structure, function, and tricuspid valve competence in patients undergoing PPM implantation. Methods: In this prospective observational study, 20 patients were divided equally into two groups: apical and septal pacing. Comprehensive echocardiographic evaluations were performed pre- and one month post-implantation. Parameters included RV and right atrial (RA) size, RV fractional analyses included Mann-Whitney U tests and visualizations using radar plots and p-value heatmaps. Results: Postimplantation, the apical group demonstrated significantly greater RV and RA dilation, elevated PAP, and reduced E' velocities, indicative of impaired diastolic function and increased right-sided load. In contrast, the septal group exhibited more stable dimensions and preserved diastolic function. Although baseline mild TR was more prevalent in the apical group (P<0.024), no significant intergroup differences in TR severity were observed at follow-up. Other clinical risk factors were comparable between groups. Conclusions: Septal lead positioning is associated with more favorable right heart geometry and hemodynamics than apical pacing in the early post-implantation period. These preliminary findings support septal pacing as a potentially superior strategy for long-term cardiac preservation, but the small sample size limits generalizability and warrants confirmation in larger, randomized trials.