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Permanent Pacemaker Insertion Periprocedural Care

  • Author: Chakri Yarlagadda, MD, FACC, FSCAI, FASNC, CCDS; Chief Editor: Richard A Lange, MD, MBA  more...
 
Updated: May 21, 2014
 

Equipment

Equipment required for permanent pacemaker insertion includes the following:

  • Fluoroscope
  • Instrument tray
  • Pacing system analyzer
  • Introducer kit
  • 1-2% lidocaine or bupivacaine
  • Antimicrobial flush and saline for pocket irrigation
  • Emergency crash cart with medications
  • Battery or electric cautery
  • Suture material
  • External pacemaker/defibrillator

Fluoroscopy and electrocardiography (ECG) are essential. Single-plane fluoroscopy using anteroposterior, 30° right anterior oblique, and 45° left anterior oblique views usually suffices for transvenous implantation from either the right or the left pectoral approach. High-resolution digital C-arm fluoroscopy is generally needed for implants performed in the operating room (OR). Currently, initial lead sensing and capture measurements are obtained by system analyzers, which may be freestanding or built into the pacer programmer.

Instrument requirements vary with surgical preferences. A minivascular tray from the OR provides an excellent starting point and can be modified as needed. Suture materials include both nonabsorbable material for lead and device anchoring and absorbable material for pocket closure. Antimicrobial flush and saline for pocket irrigation should be available. If phlebography is to be performed, an appropriate intravenous (IV) contrast agent must be available.

Pacemaker/defibrillator

Although pacemaker leads from different manufacturers vary significantly, they can be classified into 1 of 2 types on the basis of the fixation mechanism at the tip:

  • Active fixation with a screw
  • Passive fixation with tines

The pacemaker battery usually lasts about 6-12 years, depending on type, programming, frequency of use, and lead characteristics. When the battery is depleted, the pulse generator must be replaced. The previously placed leads can be used if they are functioning properly.

Current pacemakers are programmable to different modes. A standardized code for pacemaker nomenclature was developed jointly by the North American Society of Pacing and Electrophysiology (NASPE—the older name for what is now the HRS) and the British Pacing and Electrophysiology Group (BPEG).[7] The code has 5 positions, each of which denotes a function of the lead in the cardiac chamber; letter values are assigned to the positions (see the Table below). The fifth position is not widely used in current practice.

Table. Standardized Code for Pacemaker Nomenclature (Open Table in a new window)

I II III IV V
Chamber(s) paced Chamber(s) sensed Response to sensing Rate modulation Multisite pacing
O = None O = None O = None O = None O = None
A = Atrium A = Atrium T = Triggered R = Rate modulation A = Atrium
V = Ventricle V = Ventricle I = Inhibited   V = Ventricle
D = Dual (A+V) D = Dual (A+V) D = Dual (T+I)   D = Dual (A+V)
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Patient Preparation

Anesthesia

Implantation of pacing systems usually involves a combination of local anesthesia and conscious sedation. Infiltration of skin and subcutaneous tissue at the implant site with 1-2% lidocaine or bupivacaine provides sufficient local anesthesia for the majority of implant procedures. Conscious sedation may be administered in the form of carefully titrated IV midazolam and fentanyl by trained and qualified personnel. On rare occasions, general anesthesia may be required in an extremely uncooperative or high-risk patient.

Positioning

The patient is usually positioned on his or her back, with the arms tucked. If air embolism occurs, the patient should be placed in the Trendelenburg position with a left lateral decubitus tilt; this may prevent the movement of air into the right ventricle and onward into the left side of the heart.

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Monitoring and Follow-Up

Patients should plan to have someone drive them home after discharge.

Routine oral antibiotics should be continued for 3-10 days after the time of discharge. Discharge medications must be optimized after pacemaker implantation, especially atrioventricular blocking medications.

The method and frequency of pacemaker checkup are determined by the physician involved in pacemaker follow-up care and are based on the individual patient’s needs, the type of pacemaker used, and any underlying medical conditions present.

Medicare-allowed pacemaker checks are as follows:

  • Single-chamber pacemakers - 2 pacemaker checks in the first 6 months after insertion, then 1 every 12 months or during any pacer malfunction
  • Dual-chamber pacemakers - 2 pacemaker checks in the first 6 months after insertion, then 1 every 6 months or during any pacer malfunction

There is a 90-day global period for pacemaker insertion; as a rule, any pacer checks during that time are included in the global period.

Pacemakers can be followed via transtelephonic monitoring or remotely via wireless technology. Although these technologies provide some comfort to the patient, they offer only limited interrogation data and pacemaker information to the monitoring physician. One of the disadvantages of remote monitoring is that it does not permit programming or changes to the pacemaker.

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Contributor Information and Disclosures
Author

Chakri Yarlagadda, MD, FACC, FSCAI, FASNC, CCDS Director of Non-Invasive Cardiology, St Joseph Health Center; Invasive Cardiologist, Ohio Heart Institute

Chakri Yarlagadda, MD, FACC, FSCAI, FASNC, CCDS is a member of the following medical societies: American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, Heart Rhythm Society, American Society of Nuclear Cardiology

Disclosure: Nothing to disclose.

Chief Editor

Richard A Lange, MD, MBA President, Texas Tech University Health Sciences Center, Dean, Paul L Foster School of Medicine

Richard A Lange, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, Association of Subspecialty Professors

Disclosure: Nothing to disclose.

Acknowledgements

Acknowledgments

The author thanks Dr. Walter Paladino for his contribution of the cardiac resynchronization therapy material.

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Table. Standardized Code for Pacemaker Nomenclature
I II III IV V
Chamber(s) paced Chamber(s) sensed Response to sensing Rate modulation Multisite pacing
O = None O = None O = None O = None O = None
A = Atrium A = Atrium T = Triggered R = Rate modulation A = Atrium
V = Ventricle V = Ventricle I = Inhibited   V = Ventricle
D = Dual (A+V) D = Dual (A+V) D = Dual (T+I)   D = Dual (A+V)
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