SA Journal of Radiology

ISSN: (Online) 2078-6778, (Print) 1027-202X

Page 1 of 13 Original Research

Chest radiographs of cardiac devices (Part 1):

Cardiovascular implantable electronic devices, cardiac
valve prostheses and Amplatzer occluder devices

Authors: Several new innovative cardiac devices have been created over the last few decades. Chest
Rishi P. Mathew1 radiographs (CXRs) are the most common imaging investigations undertaken because of their
Timothy Alexander1
Vimal Patel1
value in evaluating the cardiorespiratory system. It is important for the interpreting radiologist
Gavin Low1 to not only identify these iatrogenic objects but also to assess for their accurate placement, as
well as for any complications related to their placement, which may be seen either on the
Affiliations: immediate post-procedural CXR or on a follow-up CXR.
1
Department of Radiology
and Diagnostic Imaging, Keywords: Chest radiographs; pacemaker; implanted cardioverter defibrillators; cardiac
Faculty of Medicine and resynchronisation therapy; implantable loop recorder; valve replacement; transcatheter valve
Dentistry, University of replacement; amplatzer septal occluder; amplatzer ductal occluder.
Alberta, Edmonton, Canada

Corresponding author:
Rishi Mathew, Introduction
dr_rishimathew@yahoo.com
Over the last few decades, several new innovative cardiac medical devices have been created.
Dates: Almost all of the patients with implanted cardiac devices such as pacemakers, implantable
Received: 04 Mar. 2019 cardioverter defibrillators (ICDs), cardiac resynchronisation therapy (CRT) devices, implantable
Accepted: 05 May 2019 loop recorders (ILR) and cardiac prosthetic valves undergo chest radiographs (CXRs) on a regular
Published: 31 July 2019
basis. Therefore, it is not uncommon for the resident, radiologist, intensivist or physician to be
How to cite this article: presented with a conundrum of CXRs having a variety of these devices on a day-to-day basis.
Mathew RP, Alexander T, Chest radiographs are the initial modality for evaluating the device location and its integrity after
Patel V, Low G. Chest implantation and for diagnosis of complications and malfunction.1 The intention of this article is
radiographs of cardiac to inform the readers about these cardiac devices, their indications, their proper position on CXRs
devices (Part 1):
Cardiovascular implantable and commonly associated complications.
electronic devices, cardiac
valve prostheses and
Amplatzer occluder devices.
Cardiovascular implantable electronic devices
S Afr J Rad. 2019;23(1), Cardiovascular implantable electronic devices (CIEDs) include implantable cardiac pacemakers,
a1730. https://doi.org/​ ICDs, CRT devices (also known as biventricular devices) and implantable cardiac monitors. In
10.4102/sajr.v23i1.1730
2012 alone, at least 3 million patients were implanted with CIEDs.2 In the United States,
Copyright: approximately 100 000 ICDs and 300 000 pacemakers are implanted annually,3 while in the UK,
© 2019. The Authors. the 10-year average growth rate for pacemakers and ICDs is 4.7% and 15%, respectively.4 It is
Licensee: AOSIS. This work important to understand the basic functions and differences between various CIEDs, as well as to
is licensed under the recognise them on a radiograph.
Creative Commons
Attribution License.
The CIED is composed of two main components: the pulse generator encased in titanium and the
pacemaker or ICD lead(s). The pulse generator (Figure 1) comprises the circuitry, a lithium battery
and the connector port. The CIED lead has five major parts: a conductor, insulation (silicone rubber
or polyurethane), electrode(s), a fixing mechanism and a terminal connector pin. Proximally the
leads are connected to the generator by the terminal connector by means of a connector block.5 Lead
tips can be fixed actively or passively. Leads placed passively have radiolucent ‘tines’ at their end
that anchor the lead tips in position. With time, the myocardium surrounding the lead tip undergoes
fibrosis, further securing the lead tip in place. Active fixation leads have a retractable screw at its
end which is deployed when the lead is placed in position. Specific situations where active fixation
is used include right ventricular (RV) leads in the outflow tract and in situations where the right
atrial (RA) leads must be secured to the tissue for stability. Active fixation leads are more commonly
used in younger patients as it can be extracted much easier than passive fixation leads.6
Read online:
Scan this QR
code with your Pacemakers
smart phone or
mobile device A pacemaker is a medical device that regulates the heart rate by electrical impulses delivered
to read online.
through electrodes to the heart muscles. The primary aim of this device is to maintain an adequate

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 Page 2 of 13 Original Research

heart rate so as to not fall below a certain limit (mostly 60 Temporary pacemakers
beats/min), either because of a dysfunction of the These pacemakers are meant for short-term use during
heart’s natural pacemaker or because of a block in the hospitalisation such as for bradydysrhythmia following a heart
electrical conduction system of the heart.4,5 Pacemakers can attack, cardiac surgery or drug overdose. The main equipment
be temporary or permanent. of the temporary pacemaker (the external pacemaker generator)
is located outside the body and may be attached to the patient’s

FIGURE 1: Basic components of a cardiovascular implantable electronic device

(CIED) generator include the battery (black star), the circuitry (white star) and the
terminal connector ports (arrow heads). The pacemaker generator contains the
manufacturer logo (white arrow). This pacemaker is MRI conditional as indicated FIGURE 3: A chest radiograph (CXR) showing abandoned pacemaker leads in the
by the curvilinear line (black arrow) near the manufacturer logo. right atrium and the right ventricle.

a b

FIGURE 2: Frontal (a) and lateral (b) view chest radiographs showing a dual-chamber pacemaker with the right atrial lead (arrow) in the right atrial appendage forming a
‘J’ on the lateral view and the right ventricular lead (arrow head) pointing towards the cardiac apex.

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skin by a tape or body by a belt.6 The method of choice for be placed under the skin of the abdomen, inframammary
temporary pacing in the intensive care unit (ICU) is transvenous site in women for cosmetic reasons and right infraclavicular
pacing. Temporary epicardial pacing is the most common choice site for the left handed.4,10 During the insertion of a pacemaker,
following cardiac surgery and for permanent pacing in children. the standard procedure is a fluoroscopic evaluation of the
Other alternatives include transthoracic, transesophageal or positioning of the pacemaker electrodes, followed up by a
transcutaneous pacing routes.7,8 CXR post insertion. Chest radiographs are also useful for
identifying abandoned pacemaker leads (Figure 3) and
Permanent transvenous pacemakers complications (Figure 4a and b) which have been elaborated
These pacemakers are meant for chronic cardiac rhythm on in detail in Table 1.4,10
dysfunction with abnormally low heart rate and, in general,
Recently, leadless pacemaker systems have been developed
have a sensing (and/or pacing) lead in the right atrium and
as a minimally invasive option for patients requiring
a pacing (and/or sensing) lead in the right ventricle.
single-chamber pacemaker placement. The two RV leadless
Permanent pacemakers can be single-chamber pacemakers
pacemaker systems currently available for clinical use are
(usually with a single lead in the apex of the right ventricle the Nanostim™ Leadless Pacemaker System (LPS) (St. Jude
especially for patients with atrial fibrillation; however, a Medical) and the Micra™ Transcatheter Pacing System (TPS)
single lead may be seen in the atrium for patients with sick (Medtronic), both of which are inserted via femoral venous
sinus syndrome), dual-chamber pacemakers (with two access and implanted directly into the RV wall. On CXRs,
leads, one in the RA appendage and the second in the RV these devices appear as a linear radiopaque material
apex) (Figure 2a and b) or biventricular pacemakers also implanted into the RV wall. Potential complications that can
known as CRT devices that have been developed for be identified on CXRs include device dislodgment and
treating severe congestive heart failure. The CRT device cardiac perforation.11
will be discussed later separately.1,8,9 The leads of the
permanent pacemakers are inserted using a transvenous Implanted cardioverter defibrillators
route usually through the left or right subclavian vein or An ICD is a medical device capable of producing a large
rarely through the internal jugular, axillary or femoral vein. amount of electrical energy in a single output, used to
The pulse generator is implanted into the subcutaneous defibrillate the heart. It is mainly used in patients
layer of chest below the clavicle and above the pectoral with tachydysrhythmias (e.g. ventricular tachycardia or
muscle (prepectoral fascia). Rarely, the pulse generator may ventricular fibrillation) and for preventing cardiac arrest.

a b

Note: The right ventricular (RV) lead is accurately placed. In addition, multiple prosthetic valve replacements are noted in this patient.
FIGURE 4: Frontal (a) and lateral (b) view chest radiographs (CXRs) showing a dual-lead pacemaker with the right atrial lead (arrow) abnormally positioned in the inferior vena cava.

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An ICD usually comprises of a single lead with one or two defibrillating shock. When a two-shock-coil device is
shock coils. A shock coil has a relatively thick electrode to placed accurately, one shock coil will be terminating at the
reduce the risk of damage to the myocardium from the brachiocephalic vein–SVC junction and the second coil in

TABLE 1: How to assess cardiac implantable electronic devices on chest radiographs.

Step How to assess
Step1: Look for immediate Look for immediate post-procedural complications, for example, myocardial perforation (ventricular lead located in abnormal location such as
post-procedural complications: subdiaphragmatic location, pericardial/pleural effusion, cardiac tamponade or extracardiac stimulation of the diaphragm, intercostal or
abdominal muscles), pneumothorax and haemothorax.
Step2: Differentiate between a An ICD comprises of a single lead with one or two shock coils. As these shock coils are radiopaque, they can be readily identified on a CXR,
pacemaker and an ICD. enabling ICDs to be differentiated from a pacemaker.
Step 3: Evaluate the electrode The proximal end of an electrode has an insertion port that attaches the lead to the generator. The electrode should slightly extend beyond the
port insertion sites connecting connector for the device to function properly. If not, repositioning of the electrode will be required.
to the generator.
Step 4: Look for lead damage Normally, the lead should follow a linear pathway without forming any loops, as it may cause cardiac arrhythmia and even migration and
or breakage by tracing their translocation of the lead tip. In patients with normal anatomic variants such as left SVC or congenital cardiac conditions (e.g. patent foramen
entire course. ovale and transposition of the great arteries), the leads may show an abnormal course or location of their ends. It is not uncommon to see CXRs
with abandoned leads because fibrous tissue around the abandoned leads can make their removal unsafe (Figure 3). The incidence of lead
breakages is < 5% and can occur anywhere along its pathway. The commonest sites are at their attachment with the generator or at the entry of
the subclavian vein, where it gets crushed between the clavicle and first rib (also known as clavicle crush or subclavian crush). Electrode fracture
occurs when there is a break in continuity between two extremes (Figure 9).
Step 5: Confirm that the The RA lead should be in the RA appendage. On a posterior–anterior (PA) radiograph, the RA lead has a slight medial course, while on a lateral
electrode tip is accurately CXR, its location is anterior subtending an angle <90 and forming a ‘J’. The RV lead on a PA CXR has its tip pointing towards the cardiac apex and
positioned and does not should be to the left of the spine, while on the lateral view, the lead should curve along the course of the right atrial lateral wall, passing the
change on follow-up CXRs. tricuspid valve and reaching the apex of the heart, pointing anteriorly and slightly superiorly (or inferiorly). Alternative placement sites in the RV
include the outflow tract. In patients with normal anatomic variants such as left SVC or congenital cardiac conditions (e.g. patent foramen ovale
and transposition of the great arteries), the leads may show an abnormal course or location of their ends.5,10
In patients with CRT devices, it is normal to see an electrode in the coronary sinus (left ventricular [LV] electrode), and for it to be accurately
placed in the coronary sinus, the electrode tip needs to be at the posterolateral coronary vein, anterior interventricular vein or the middle
cardiac vein. On a frontal radiograph, it is difficult to differentiate an RV electrode from an LV one. For this purpose, a lateral CXR can be more
useful. In this case, the RV electrode is located anteriorly in the lateral segment, while the LV electrode is located in the posterior segment of the
cardiac silhouette. Although the above-mentioned positions are the optimal location for the electrodes, some amount of variation is permissible
as long as the obtained potentials are good. Hence, it is always advisable to compare a follow-up CXR with prior ones to identify any change in
position of the electrode(s) indicating dislocation or migration.10
Step 6: Identify if the CIED is By evaluating the pacemaker generator, the radiologist can determine if the implanted pacemaker is magnetic resonance imaging (MRI)
MRI conditional. conditional thereby contributing to patient management by determining whether an MRI is the best imaging study to answer a clinical question
(if it is indicated), as well as suggesting ‘absolute’ contraindications for non-MRI conditional CIEDs which include CIED implanted <6 weeks prior,
CIED with retained or fractured device leads, surgically placed permanent epicardial pacing leads and temporary intracardial or epicardial pacer
devices with the external generator still attached. Intubated or heavily sedated patients are considered as a relative contraindication. However,
these contraindications are slightly disputed by some experts.
Step 7: Evaluate the correct Complications that can occur at the pacemaker pocket are hematoma, infections and presence of air-fluid level. Two syndromes are
position of the pacemaker associated with abnormal rotation of the pacemaker generator, namely Twiddler’s syndrome and Reel syndrome. In Twiddler’s syndrome, the
casing inside the pocket and casing is rotated along the axis of its leads, usually as a result of the patient’s own manipulation, causing the leads to get twisted around the
look for complications. casing, leading to displacement at their ends. Reel syndrome is a variant of the Twiddler’s syndrome, where the casing rotates along its
sagittal axis.
ICD, implantable cardioverter defibrillators; SVC, superior vena cava; RA, right atrial; RV, right ventricular; LV, left ventricular; CIED, cardiac implantable electronic devices; CXR, chest radiographs;
CRT, cardiac resynchronisation therapy; MRI, magnetic resonance imaging.

a b

Note: The proximal shock coil is at the brachiocephalic vein–superior vena cava junction (arrow) and the distal shock coil is in the right ventricle (arrow head).
FIGURE 5: Chest radiographs posterior–anterior (a) and lateral views (b) showing a dual-lead implantable cardioverter defibrillator with its characteristic shock coils
implanted in a 62-year-old female patient with non-ischaemic cardiomyopathy.

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the RV (Figure 5a and b). As these shock coils are securely and directly over the CIED generator to switch the
radiopaque, they can be readily identified on a CXR, CIED to asynchronous pacing mode and hence prevent the
enabling ICDs to be differentiated from a pacemaker.5,10,12 EMI from interfering with the device pacing. Once the
A newer approach is to place a subcutaneous ICD lead to magnet has been removed, the CIED will revert to its original
the left of the sternum (Figure 6). programmed settings.9

During surgery in the operating room, a CIED can sense an A detailed stepwise approach to the assessment of an ICD
external magnetic interference (EMI) that can affect including its associated complications (Figures 8a and b, 9
its pacing function. The source of the EMI may include and 10) on a CXR is like a pacemaker and is elaborated on in
Table 1.
electrocautery, external defibrillation, radio frequency
ablation (RFA) and dental instruments. A cardiac device
magnet (Figure 7) may be used temporarily by placing it Cardiac resynchronisation therapy devices
(implantable cardioverter defibrillator and
pacemaker combinations)
ICD and pacemaker leads can be used in various
combinations to produce a CRT device. The most common

Note: The implantable cardioverter defibrillator lead is implanted subcutaneously and

parallel, approximately 1 cm – 2 cm to the left of the sternum.
FIGURE 6: A subcutaneous implantable cardioverter defibrillator implanted in a
27-year-old male patient with hypertrophic cardiomyopathy. FIGURE 7: A chest radiograph showing a doughnut magnet placed over a pacemaker.

a b

FIGURE 8: Posterior–anterior (a) and lateral (b) chest radiograph views showing a dual-lead implantable cardioverter defibrillator with a single right ventricular shock coil.
Note its right atrial lead (arrow) malpositioned in the superior vena cava.

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combination is a biventricular pacemaker with an ICD ICD (CRT-D) or a standalone pacemaker (CRT-P). The
(Figure 11a and b), where the two pacemaker leads are main aim of this device, in addition to a being pacemaker
noted in the right atrium and LV, while the shock lead of or ICD, is to synchronise the left ventricular contraction
the ICD is in the RV. Cardiac resynchronisation therapy to improve the symptoms of CHF.5,10,12 The assessment
devices are mainly used for treating congestive heart of a CRT device on a CXR is no different from the other
failure (CHF). The CRT device can be more commonly an CIEDs.

FIGURE 9: A dual-lead implantable cardioverter defibrillator with a subtle fracture FIGURE 10: A dual-lead implantable cardioverter defibrillator showing externalised
(arrow) in the proximal portion of the right atrial lead, close to the generator. conductors (arrows) of its right ventricular lead, leading to its failure.

a b

FIGURE 11: Frontal (a) and lateral (b) chest radiographs showing a cardiac resynchronisation therapy device with its pacemaker leads (arrow heads) in the right atrial
appendage and the left ventricle, and its implantable cardioverter defibrillator shock coils (arrows) in the superior vena cava and right ventricular apex.

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By closely evaluating the CIED generator, a radiologist can

determine if the device is MR conditional, as there are
several ‘absolute’ contraindications to performing magnetic
resonance imaging (MRI) in patients implanted with non-
MR conditional CIEDs (elaborately detailed in Table 1),13
although some of these contraindications remain slightly
disputed.14

Insertable cardiac monitor or implantable

loop recorder
An insertable cardiac monitor (ICM) or ILR (Figure 12) is a
miniaturised subcutaneous electrocardiographic monitoring
device that has been extensively used for evaluating patients
with unexplained syncope, symptomatic palpitations in
adults, transient or occult atrial fibrillation (AF) and in the
evaluation of a stroke.12 When compared to pacemakers
and ICDs, ICMs do not require central venous access or
direct contact with the endocardium, thereby negating the
risk for endocardial infection. The device is generally
Note: The patient had a history of recurrent dizziness and syncope.
implanted in the subcutaneous tissue overlying the left
FIGURE 12: Chest radiograph of a 67-year-old female patient with an implantable
loop recorder. pectoralis muscle with a 1 cm – 2 cm incision that does not

a b

Source: Reproduced with permission: Cressman S, Rheinboldt M, Klochko C, Nadig J, Spizarny D. Chest radiographic appearance of minimally invasive cardiac implants and support devices: What
the radiologist needs to know. Curr Probl Diagn Radiol. 2019;48(3):274–288. https://doi.org/10.1067/j.cpradiol.2018.05.006
PV, pulmonary valve; AV, aortic valve; MV, mitral valve; and TV tricuspid valve.
FIGURE 13: By drawing an imaginary line extending from the left atrial appendage to the right cardiophrenic angle on a posterior–anterior (a) chest radiograph and an
imaginary line from the carina to the cardiac apex on the lateral view (b), the cardiac valves can be identified.16

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require conscious sedation. On a CXR, the ICM appears like

a USB drive with no wires or leads attached to it. Insertable
Cardiac valves and valve
cardiac monitor mimics on a PA CXR include a USB flash replacements or repair
drive, an e-vape device and a leadless cardiac pacemaker Landmarks of the cardiac silhouette and of the thorax can
in the RV, which can be differentiated from them on a enable the identification of heart valves on a CXR. By
lateral CXR. 1,15 drawing an imaginary line extending from the left atrial
appendage to the right cardiophrenic angle (Figure 13)16
on a PA CXR and a line extending from the carina to the
apex on the lateral view, positions of the valves can be
roughly estimated. The pulmonic valve is the most
superiorly positioned valve in both views, appearing in
partial profile on both projections. On both views, the
aortic valve is located superior to the axis line, appearing
in profile and in front on the frontal and lateral views,
respectively. In contrast, the mitral valve is located inferior
to the axis lines on both views, appearing en face on the
frontal projection and in profile on the lateral view. The
tricuspid valve is located the most inferiorly on both
projections, appearing anteriorly and en face on the
lateral view. Nevertheless, because of anatomical and
physiological variations and differences in radiographic
projections, valve identification based solely on CXR can
be unreliable, necessitating the need for additional details
such as clinical history.16

Valvular heart disease is associated with significant

morbidity and mortality and affects roughly more than
100 million people worldwide, and the current
standard of management is surgical valve replacement
(Figures 14–20). Alternatively, transcatheter valve
FIGURE 14: Chest radiograph showing a mitral annuloplasty C ring (arrow). Note the
replacement without surgery has been gaining popularity
dual-lead pacemaker with accurately placed right atrial and right ventricular leads. over the last decade, especially in patients not suitable for

a b

FIGURE 15: Frontal (a) and lateral (b) chest radiographs showing mitral (perimount tissue) valve replacement (arrow) in a patient with severe mitral stenosis.

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surgery. Based on the leaflet material, the two types of Identification of the prosthetic heart valve on a CXR is
prosthetic heart valves available are the mechanical and made possible by detecting any or all its radiopaque parts
biological or bioprosthetic heart valves (BHVs).17 The various which may include the base ring, stent, struts, cage, ball or
types of biological and mechanical prosthetic valves have disc. In some cases, a prosthesis may have no radiopaque
been highlighted in Table 2, and they all look slightly different component and hence cannot be identified radiographically.
on imaging. The choice between mechanical valve and In most cases, the base ring is radiopaque. Several
bioprosthetic valve remains controversial and is based on prosthetic valves have radiopaque struts or stents above
multiple parameters (Tables 2 and 3).18,19 or below the base ring. If the projections are long, the

a b

FIGURE 16: Frontal (a) and lateral (b) chest radiographs showing an aortic valve (perimount magna ease tissue valve) replacement (arrow) in a 76-year-old male patient
with severe aortic stenosis.

a b

FIGURE 17: Frontal (a) and lateral (b) chest radiographs showing transcatheter aortic valve replacement (arrow) in an 81-year-old female patient with severe
aortic stenosis.

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a b

FIGURE 18: Frontal (a) and lateral (b) chest radiographs showing an isolated prosthetic tricuspid valve replacement (Starr Edwards valve) (arrow) in a 51-year-old male
patient with a history of Ebstein’s anomaly. Note the implanted pacemaker with its epicardial leads.

a b

FIGURE 19: Frontal (a) and lateral (b) chest radiographs showing prosthetic aortic (black arrow), mitral (white arrow) and tricuspid (arrow head) valves in a 72-year-old
female patient with a history of aortic and mitral stenosis, tricuspid regurgitation and complete heart block.

prosthetic heart valve is either a ball-in-cage or

bioprosthesis. Literature sources are available,20 providing
Amplatzer septal occluder and
detailed algorithms guiding in the identification of Amplatzer ductal occluder
prosthetic heart valves on CXRs which is beyond the scope The Amplatzer septal occluder (ASO) (AVP, AGA Medical
of this article. Corp., Golden Valley, MN, USA) is the most commonly used
device for transcatheter closure of secundum atrial septal
A stepwise approach to the evaluation of CXRs following defects. The location of the ASO on a CXR is based on the
cardiac valve replacement is elaborated in Table 4.21 position of the secundum atrial septal defect (ASD). On

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a b

FIGURE 20: Frontal (a) and lateral (b) chest radiographs (CXRs) showing prosthetic pulmonary valve replacement (arrows).

TABLE 2: Types of prosthetic heart valves. TABLE 4: A stepwise approach for the evaluation of chest radiographs following
Heart valve Type Prosthetic cardiac valve replacement.
Step Evaluation of the cardiac valve(s)
Biological or Stented Porcine bioprosthesis
bioprosthetic heart Step 1 Identification of the valve(s) replaced.
valves (BHVs) Pericardial bioprosthesis
Stentless Porcine bioprosthesis Step 2 Identify the number of valve(s) replaced.
Pericardial bioprosthesis Step 3 Evaluate the position and orientation of the valve(s) replaced.
Aortic homograft Step 4 As valve replacement is most often done through a median sternotomy,
look for changes in the cardiac and mediastinal contour.
Pulmonary autograft (Ross procedure)
Step 5 Evaluate for post-valve replacement complications: Once the native
Sutureless - valves have been replaced, a radiologist must bear in mind
complications such as paravalvular insufficiency (structural changes of
Transcatheter - the base ring, struts or occlude), features of obstruction (thrombus
Mechanical heart valves Bileaflet - formation or tissue overgrowth), thromboembolism, infective
endocarditis and sequelae of chronic anticoagulant use, for example,
Single tilting disk - pulmonary and gastrointestinal haemorrhage. On follow-up CXRs, look
Caged ball - for the presence or absence of calcifications of the valve, coronary
artery or cardiac wall, evidence of pulmonary artery or vein
hypertension and pleural pathology.
TABLE 3: Bioprosthetic and mechanical heart valves: advantages and disadvantages. Step 6 Evaluate the ribs for rib fractures or rib separations from right or left
thoracotomy (e.g. a prior mitral commissurotomy may show a
Prosthetic valve Advantages Disadvantages separation or fractured left posterior 5th and 6th ribs, a right
Bioprosthetic • N o need for lifelong anticoagulation • S horter durability and thoracotomy may be because of a prior lung surgery or mitral or
• Lower risk for bleeding hence higher tricuspid plication, etc.).
• Can be used in patients re-operation rates CXRs, chest radiographs.
contraindicated for anticoagulation,
for example, pregnancy
• Preferred in older patients, patients
with cancer and renal failure on sites of migration are the right cardiac chambers and
haemodialysis pulmonary artery, while left-sided migration is rare.23
Mechanical • L onger durability and lesser • Increased risk of
re-operation rates thrombosis
• Desirable haemodynamic • Lifelong need for The Amplatzer ductal occluder (ADO) is a mushroom-
properties: low gradients and low anticoagulation
disturbances in flow • Increased risk of shaped self-expandable nitinol wire mesh used for
• Preferred in younger patients bleeding
• Preferred in patients with already occluding large patent ductus arteriosus (PDA), while
another mechanical heart valve smaller PDAs are occluded by the transcatheter method
using Gianturco coils. A recognised complication with the
frontal CXRs (Figure 21a), the ASO is projected to the right or ADO, like the ASO, is device embolisation or migration
over the spinous processes between the T7 and T9 vertebral (Figure 22a and b).24
bodies, and on lateral CXRs (Figure 21b), the ASO is projected
anterior to or over the hilar-caval line.22 ASO migration or Ethical consideration
embolisation is a recognised complication with an incidence All ethical considerations have been taken into account. No
of 0.4% – 1.1%, which can be identified on a CXR. Common patient identity or patient information has been revealed.

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a b

Source: Reproduced with permission: Cressman S, Rheinboldt M, Klochko C, Nadig J, Spizarny D. Chest radiographic appearance of minimally invasive cardiac implants and support devices: What
the radiologist needs to know. Curr Probl Diagn Radiol. 2019;48(3):274–288. https://doi.org/10.1067/j.cpradiol.2018.05.006
Note: Subset image showing an Amplatzer septal occluder.
FIGURE 21: Chest radiographs showing a normally positioned Amplatzer septal occluder (arrow) in a 4-year-old girl with a history of a secundum atrial septal defect. Note that
the ASO is projecting over the right lateral margins of the T8 vertebral body on the frontal view (a) and located anterior to the hilar-caval line on the lateral view (b).16

a b

FIGURE 22: A migrated amplatzer duct occluder placed for patent ductus arteriosus. Aortogram in the oblique anterior–posterior view (a) shows transcatheter deployment
of the amplatzer duct occluder in the lumen of the aorta. Post-procedural chest radiograph (b) shows migration of the device (arrow).

Conclusion and important role in the evaluation of these devices. An

early and accurate identification of device malfunction,
As more and more patients are living with CIEDs and
fracture or migration can help prompt the physician or
prosthetic valves, it is important that residents, radiologists
and physicians are aware of these devices and recognise surgeon to intervene in a timely manner and help avoid
them on a CXR. Radiologists in particular have a specific preventable life-threatening catastrophes.

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Competing interests 7. Kossaify A. Temporary endocavitary pacemakers and their use and misuse: The
least is better. Clin Med Insights Cardiol. 2014;8:9–11. https://doi.org/10.4137/
CMC.S13272
The authors declare that they have no financial or personal
8. Godoy MC, Leitman BS, De Groot PM, Vlahos I, Naidich DP. Chest radiography
relationships that may have inappropriately influenced them in the ICU: Part 2, Evaluation of cardiovascular lines and other devices.
AJR Am J Roentgenol. 2012 Mar;198(3):572–581. https://doi.org/10.2214/AJR.​
in writing this article. 11.8124
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implantable electronic devices undergoing noncardiac surgery. Health Serv
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Funding neuroradiologist. AJNR Am J Neuroradiol. 2017 Dec;38(12):2222–2230. https://
doi.org/10.3174/ajnr.A5314
This research received no specific grant from any funding 14. Muthalaly RG, Nerlekar N, Ge Y, Kwong RY, Nasis A. MRI in patients with cardiac
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Data availability statement 2013;8(8):e71544. https://doi.org/10.1371/journal.pone.0071544

Data sharing is not applicable to this article as no new data 16. Cressman S, Rheinboldt M, Klochko C, Nadig J, Spizarny D. Chest radiographic
appearance of minimally invasive cardiac implants and support devices: What the
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The views and opinions expressed in this article are those of 18. Altaani HA, Jaber S. Tricuspid valve replacement, mechanical vs. biological valve,
which is better? Int Cardiovasc Res J. 2013;7(2):71–74.
the authors and do not necessarily reflect the official policy or
19. Tillquist MN, Maddox TM. Cardiac crossroads: Deciding between mechanical or
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https://doi.org/10.2147/PPA.S16420

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