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Pediatric Pacemaker Implantation Technique

  • Author: Charles I Berul, MD; Chief Editor: Stuart Berger, MD  more...
Updated: Apr 01, 2014

Approach Considerations

Provide a thorough and adequate explanation of pacemaker implantation procedures to the patient. Document indications for permanent pacing and outline the plan for route of access. Make relevant surgical decisions after comprehensive consideration of the following factors:

  • Transvenous versus epicardial approach
  • Single-chamber pacing versus dual-chamber pacing versus cardiac resynchronization therapy (CRT)
  • Vascular access and continuity
  • Prepectoral versus submuscular pocket
  • Handedness of the patient and left-side versus right-side implantation
  • Presence of structural heart disease, intracardiac shunts, and obstruction to the right heart chambers
  • Relevant medical, surgical, and anesthesia history
  • Allergies
  • Risks of the procedure, including pacemaker-specific risks
  • Finite battery longevity, lead failure, and likely potential for reoperation

Implantation of Pacemaker

A sterile environment is absolutely essential for implantation. Proper facilities include an operating room, a cardiac catheterization laboratory, or an electrophysiology laboratory. The implantation procedure may be performed with either general or local anesthesia, depending on the patient’s age and the planned route of implantation.

For the transvenous approach, one can perform either a cephalic vein cutdown or percutaneous subclavian (or axillary) vein puncture to access the venous system. Position a wire in the right heart with pacing leads positioned in the right atrium or ventricle. Testing is performed using cables to a pacing system analyzer, which can ascertain adequate sensing of intrinsic waves, capture thresholds, and lead impedances.

The generator is then connected to the leads, and a pacemaker pocket is fashioned either prepectorally or subpectorally, usually with blunt dissection, cauterization, or both. The generator is placed in the pocket, and the incision is closed in multiple layers.

Leaving a generous amount of slack in the lead to allow uncurling may reduce the risk of lead fracture or dislodgment with linear growth (see the image below). Studies have been performed to estimate the amount of intracardiac lead redundancy necessary to allow for anticipated growth.

Transvenous ventricular pacemaker in 2-year-old ch Transvenous ventricular pacemaker in 2-year-old child. Note abundant slack in lead to allow for growth.

The epicardial approach is typically performed via a subcostal or subxiphoid incision, a thoracotomy, or a sternotomy. The pacing leads are attached to epicardial surfaces and then tested for capture, sensing, and lead impedances. As with the transvenous approach, a pocket is created, typically in the subrectus region of the abdomen (or in the pectoral region), with subcutaneous tunneling of the leads from epicardial sites to the pocket.

As a rule, most patients remain hospitalized for 12-48 hours after the operation, depending on age, complexity, and route of access.

Aside from several weeks’ restriction from heavy lifting, extreme stretching of the accessed shoulder (for transvenous implants), and vigorous activities, patients may resume normal activities of daily living after the procedure. These restrictions are particularly important after passive lead implantation to avoid dislodgment. The incision must be kept clean and dry and typically heals within 7-10 days.

Antibiotic prophylaxis after the first 24 hours has not been demonstrated to reduce the risk of pacemaker system or pocket infection. Patients are instructed to immediately report any symptoms of possible infection.

For patients with newly implanted CRT devices, clinicians may choose to optimize the system (specifically the pacemaker timings) with the help of echocardiography.



Complications involve immune response to artificial materials and response of the body to the pacemaker system.

Pacemaker generators are typically very reliable and have a low failure rate. The lithium iodide battery has a limited longevity of 5-15 years. Battery depletion is not a complication but a normal occurrence.

Pacing leads are more prone to failure, particularly in children.[19] Leads may fail at the conductor wires or in the insulation material (polyurethane or silicone). Lead failure typically results in inappropriate sensing or capture (ie, underpacing or overpacing).

Infection of the pacemaker system is a serious complication and almost always necessitates complete system removal, intravenous antibiotics, and system replacement at a remote site. However, in selected cases, pacemaker system infection can occasionally be effectively treated with a prolonged course of antibiotics, without system removal.

Twiddler syndrome is an interesting finding caused by repetitive and often unintentional twisting of the generator in the pacemaker pocket, causing lead dislodgment or fracture and pacemaker failure.[20] It is most commonly observed in patients with behavioral issues.

Significant vascular access challenges can also relate to congenital heart diseases and surgical corrections.

Finally, chronic right ventricular pacing over long periods (eg, decades) has been shown in a small group of patients to lead to decreased cardiac function.

Contributor Information and Disclosures

Charles I Berul, MD Professor of Pediatrics and Integrative Systems Biology, George Washington University School of Medicine; Chief, Division of Cardiology, Children's National Medical Center

Charles I Berul, MD is a member of the following medical societies: American Academy of Pediatrics, Heart Rhythm Society, Cardiac Electrophysiology Society, Pediatric and Congenital Electrophysiology Society, American College of Cardiology, American Heart Association, Society for Pediatric Research

Disclosure: Received grant/research funds from Medtronic for consulting.

Chief Editor

Stuart Berger, MD Medical Director of The Heart Center, Children's Hospital of Wisconsin; Associate Professor, Department of Pediatrics, Section of Pediatric Cardiology, Medical College of Wisconsin

Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, Society for Cardiovascular Angiography and Interventions

Disclosure: Nothing to disclose.


John W Moore, MD, MPH Professor of Clinical Pediatrics, Section of Pediatric Cardiology, Department of Pediatrics, University of California San Diego School of Medicine; Director of Cardiology, Rady Children's Hospital

John W Moore, MD, MPH is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, and Society for Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Jeffrey Allen Towbin, MD, MSc, FAAP, FACC, FAHA Professor, Departments of Pediatrics (Cardiology), Cardiovascular Sciences, and Molecular and Human Genetics, Baylor College of Medicine; Chief of Pediatric Cardiology, Foundation Chair in Pediatric Cardiac Research, Texas Children's Hospital

Jeffrey Allen Towbin, MD, MSc, FAAP, FACC, FAHA is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American College of Cardiology, American College of Sports Medicine, American Heart Association, American Medical Association, American Society of Human Genetics, Cardiac Electrophysiology Society, New York Academy of Sciences, Society for Pediatric Research,Texas Medical Association, and Texas Pediatric Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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Electrocardiogram reveals sinus atrial mechanism with complete atrioventricular block and ventricular paced rhythm.
Electrocardiogram illustrates 2-year-old child with third-degree atrioventricular block.
Electrocardiogram illustrates atrial-synchronous, ventricular paced rhythm.
Illustration of normal conduction system.
Transvenous ventricular pacemaker in 2-year-old child. Note abundant slack in lead to allow for growth.
Epicardial dual-chamber implantable cardioverter defibrillator in neonate with congenital complete atrioventricular block. Two bipolar suture-on leads (1 on atrium and 1 on ventricle) are attached to DDDR pacemaker in abdomen.
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