Prevention of right ventricular perforation due to temporary pacemaker lead during transcatheter aortic valve replacement.

We read with great interest the recently published paper by Rezq et al. (1), which described the experience of the authors with cardiac tamponade complicating transcatheter aortic valve replacement (TAVR). The authors should be congratulated on sharing their experience and techniques to avoid this complication, which is associated with poor outcome. The authors identified that 52.9% of the cardiac tamponade cases (n 9) were the result of a right ventricular perforation from the temporary pacemaker lead, and in 4 of the 9 cases a helical screw lead was used (1), which has been the experience of multiple institutions when performing TAVR. In their discussion, the authors propose to use the helical screw lead as a second choice after other passive leads, due to the risk of perforation. We strongly agree with the authors that the helical screw leads provide the most reliable approach for pacing during transcatheter aortic valve implantation and for that reason we use these types of leads as a first choice in our cases. We would like to describe an additional safety measure that has essentially eliminated the risk of free right ventricular wall perforation in our experience: after placing the catheter in the right ventricle with a right anterior oblique projection, a steep left anterior oblique view is used to ensure that the tip of the catheter is pointing toward the right ventricle septum and not toward the right ventricle free wall (Fig. 1). Only after verifying the lead location in 2 planes do we screw in the helical screw lead. This approach also ensures that the thin-walled right ventricle is never perforated during TAVR. Obviously, the inter-ventricular septum