Pediatric Pacemaker Implantation Technique
- Author: Charles I Berul, MD; Chief Editor: Stuart Berger, MD more...
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
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.
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. 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. 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.
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