Should a Chest X-Ray Be Done After ICD Implantation?
Yes, a chest x-ray should be performed within 24 hours after ICD implantation to rule out pneumothorax and document lead positions.
Guideline-Based Recommendations
The European Heart Rhythm Association expert practical guide on cardiac implantable electronic devices (CIEDs) explicitly recommends that a chest x-ray should be performed within 24 hours following device implantation to exclude pneumothorax and verify lead positioning 1. This recommendation is supported by the American College of Radiology, which states that chest radiography is usually appropriate for initial imaging of patients following support device placement 2.
Clinical Rationale for Post-Implantation CXR
Detection of Acute Complications
Routine post-procedure chest x-rays effectively detect early peri-procedural complications that can impact patient morbidity and mortality:
- Pneumothorax occurs in approximately 0.8-1.2% of cases and requires prompt identification for appropriate management 1, 3
- Pericardial effusion/cardiac tamponade can develop during lead placement and is detected in approximately 1% of cases 1, 4
- Lead displacement occurs in approximately 0.5% of cases and may require repositioning 1
- Hemothorax may develop during subclavian vein access 4
Lead Position Verification
Chest x-ray confirms proper lead positioning, which is critical for device function and patient safety:
- Approximately 10% of chest radiographs demonstrate malpositioned leads requiring intervention 2
- Lead position assessment includes evaluation of ventricular and atrial lead contour and electrode placement 3
- Both PA and lateral views may be necessary for complete assessment 3
Evidence Supporting Routine CXR
A 2024 retrospective analysis of 578 consecutive device implants found that routine post-CIED implantation chest x-rays detected 16 complications (2.8%), including 7 pneumothoraxes (1.2%), 6 pericardial effusions (1%), and 3 lead displacements (0.5%) 1. The study confirmed that CXR is effective for early detection of these potentially life-threatening complications.
When CXR May Not Be Necessary
In highly selected uncomplicated cases with adequate pacing characteristics and no clinical concerns, routine CXR may have limited additional value 3. However, this approach requires:
- Subclavian vein puncture technique (not blind approach) 2
- Satisfactory immediate post-procedure device interrogation showing appropriate pacing and sensing parameters 3
- No patient symptoms suggesting complications (chest pain, dyspnea, hypotension) 3
- Experienced operator with low complication rates 1
Important Caveats
Procedure duration is the only statistically significant predictor of complications—longer procedures (127 ± 50 minutes vs. 99 ± 43 minutes for uncomplicated cases) are associated with higher complication rates and warrant more vigilant post-procedure imaging 1.
Radiographically "sub-optimal" lead positioning on initial CXR does not always predict clinical problems—14% of post-procedural radiographs showed radiologically sub-optimal positioning, but none of these patients experienced subsequent complications 3. However, this finding emphasizes the importance of clinical correlation with device interrogation data.
Rare but serious complications can occur contralateral to the access site, such as pneumothorax opposite the venous access location due to lead perforation through cardiac structures 5. This underscores the need for complete chest imaging rather than focused views.
Practical Implementation
Perform chest x-ray within 24 hours post-implantation in all patients 1. The radiograph should include:
- PA view at minimum to assess for pneumothorax and lead position 3
- Lateral view when lead position is questionable or anatomy is complex 3
- Systematic evaluation for pneumothorax, hemothorax, pericardial effusion, and lead positioning 1, 6
Device interrogation should be performed within 72 hours as recommended by European Society of Cardiology guidelines, but this does not replace the need for chest x-ray 1.