BackgroundImplanting leadless pacemakers in the right ventricular (RV) apex is prone to causing pericardial tamponade and myocardial perforation.ObjectiveTo investigate the feasibility and safety of right ventriculography-guided implantation of Micra™ leadless pacemaker (Micra™, Medtronic, Minneapolis, MN, USA) in the RV mid-septum.MethodsOne hundred eight consecutive patients who underwent Micra™ implantation intended in the mid-septum were enrolled and randomized (3:1) into the radiography group (n= 81) with assistance of right ventriculography to illustrate the RV septum and the non-radiography group (n= 27). All subjects underwent a postoperative computed tomography (CT) scan to determine the Micra™ location. The Micra™ location assessed by CT image was compared between the two groups to confirm the accuracy of the intended pacing site. The duration of the procedure, X-ray radiation dose, and time were also compared between the two groups.ResultsReconstructed CT 3-D cardiac images found the Micra™ location in the intended mid-septum in 13 patients (48.1%, 13/27) in the non-radiography group and 76 patients (93.8%, 76/81) in the radiography group (P< 0.0001 between two groups). There was no significant difference in procedure interval between the two groups while the X-ray radiation dose (564.86 ± 112.44 vs. 825.85 ± 156.12 mGy,P< 0.0001), X-ray exposure time (7.79 ± 1.43 vs. 12.03 ± 2.86 min,P< 0.0001), and the number of fluoroscopy re-positioning (2.79 ± 1.03 vs. 6.41 ± 1.82,P< 0.0001) were significantly less in the radiography group than in the non-radiography group. No implantation-related complications were observed in both groups.ConclusionRight ventriculography increases the accuracy of Micra™ implantation in the mid-septum and reduces X-ray exposure.Trial registrationThe trial registration number (ChiCTR2100051374) and date (09/22/2021).Supplementary InformationThe online version contains supplementary material available at 10.1007/s10840-022-01399-3.