Permanent Pacemaker Insertion Technique

Updated: Apr 29, 2021
  • Author: Chakri Yarlagadda, MD, FACC, FSCAI, FASNC, CCDS; Chief Editor: Richard A Lange, MD, MBA  more...
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Approach Considerations

Permanent pacemaker insertion is considered a minimally invasive procedure. Transvenous access to the heart chambers under local anesthesia is the favored technique, most commonly via the subclavian vein, the cephalic vein, or (rarely) the internal jugular vein or the femoral vein. The procedure is typically performed in a cardiac catheterization laboratory or in an operating room (OR).

The pacing generator is typically placed subcutaneously in the infraclavicular region. Occasionally, pacemaker leads are implanted surgically via a thoracotomy, and the pacing generator is placed in the abdominal area. Single-chamber and dual-chamber pacer insertion can be accomplished from either left or right pectoral sites. After appropriate sedation, the chest is prepared with an antiseptic solution, and the area is covered with sterile drapes to keep the incision area as clean as possible.

In current practice, antibiotic prophylaxis is standard for device implantation. Preoperative antibiotic use reduces the risk of pacemaker-related infections by approximately 80%. [13, 14]


Implantation of Pacemaker

Routinely, cefazolin 1 g or patient weight-based dosing is administered intravenously (IV) 1 hour before the procedure. If the patient is allergic to penicillins or cephalosporins, vancomycin 1 g IV or another appropriate antibiotic may be administered preoperatively.

Venous access

A central vein (ie, the subclavian or axillary vein) is accessed via a percutaneous approach. In patients in whom this is technically difficult because skeletal landmarks are deviated, an initial brief fluoroscopic examination will greatly reduce the time and complications associated with obtaining the access.

The subclavian vein is typically accessed at the junction of the first rib and the clavicle. On occasion, phlebography may be required to visualize the vein adequately or to confirm its patency. Some centers employ the first rib approach under fluoroscopy, with no or minimal incidence of pneumothorax.

After venous access is obtained, a guide wire is advanced through the access needle, and the tip of the guide wire is positioned in the right atrium or the vena caval area under fluoroscopy. The needle is then withdrawn, leaving the guide wire in place. If indicated, a second access will be obtained in a similar fashion for positioning of a second guide wire.

Sometimes, a double-wire technique is used, whereby 2 guide wires are inserted through the first sheath and the sheath then withdrawn, so that 2 separate sheaths can be advanced over the 2 guide wires. This technique can cause some resistance or friction during sheath or lead advancement.

Creation of pocket

A 1.5- to 2-inch incision is made in the infraclavicular area parallel to the middle third of the clavicle, and a subcutaneous pocket is created with sharp and blunt dissection where the pacemaker generator will be implanted. Some physicians prefer to make the pocket first and obtain access later through the pocket or via venous cutdown; once access is obtained, they position the guide wires as described above.

Placement of lead(s)

Over the guide wire, a special peel-away sheath and dilator are advanced. The guide wire and dilator are withdrawn, leaving the sheath in place. A stylet (a thin wire) is inserted inside the center channel of the pacemaker lead to make it more rigid, and the lead-stylet combination is then inserted into the sheath and advanced under fluoroscopy to the appropriate heart chamber. Usually, the ventricular lead is positioned before the atrial lead to prevent its dislodgment.

Making a small curve at the tip of the stylet renders the ventricular lead tip more maneuverable, so that it can more easily be placed across the tricuspid valve and positioned at the right ventricular apex or septum. Techniques for positioning the ventricular lead have been described. [15, 16]

Once correct lead positioning is confirmed, the lead is affixed to the endocardium either passively with tines (like a grappling hook) or actively via a helical screw located at the tip. The screw at the tip of the pacemaker is extended or retracted by turning the outer end of the lead with the help of a torque device. Adequate extension of the screw is confirmed with fluoroscopy. Each manufacturer has its own proprietary identification marks for confirming adequate extension of the screw.

Once the lead is secured in position, the introducing sheath is carefully peeled away, leaving the lead in place. After the pacing lead stylet is removed, pacing and sensing thresholds and lead impedances are measured with a pacing system analyzer, and pacing is performed at 10 V to make sure that it is not causing diaphragmatic stimulation. After confirmation of lead position and thresholds, the proximal end of the lead is secured to the underlying tissue (ie, pectoralis) with a nonabsorbable suture that is sewn to a sleeve located on the lead.

If a second lead is indicated, it is positioned in the right atrium via a second sheath, with the lead tip typically positioned in the right atrial appendage with the help of a preformed J-shaped stylet.

In a patient who is without an atrial appendage as a result of previous cardiac surgery, the lead can be positioned medially or in the lateral free wall of the right atrium. As with the ventricular lead, the atrial lead position is confirmed, impedance is assessed, the stylet is withdrawn, and the lead is secured to the underlying pectoralis with a nonabsorbable suture.

Positioning of pulse generator

When the leads have been properly positioned and tested and sutured to the underlying tissue, the pacemaker pocket is irrigated with antimicrobial solution, and the pulse generator is connected securely to the leads. Many physicians secure the pulse generator to underlying tissue with a nonabsorbable suture to prevent migration or twiddler syndrome.

Typically, the pacemaker is positioned superficial to the pectoralis, but occasionally, a subpectoral or inframammary position is required. After hemostasis is confirmed, a final look under fluoroscopy before closure of the incision is recommended to confirm appropriate lead positioning.

Completion and closure

The incision is closed in layers with absorbable sutures and adhesive strips. Sterile dressing is applied to the incision surface. An arm restraint or immobilizer is applied to the unilateral arm for 12-24 hours to limit movement.

A postoperative chest radiograph is usually obtained to confirm lead position and rule out pneumothorax. Before discharge on the following day, posteroanterior and lateral chest radiographs will be ordered again to confirm lead positions and exclude delayed pneumothorax.

Pain levels are typically low after the procedure, and the patient can be given pain medication to manage breakthrough pain associated with the incision site.



Access-related complications

Early access-related complications include the following:

  • Bleeding

  • Hematoma

  • Phlebitis or thrombophlebitis of the vein

  • Local infection

  • Arterial injury or puncture

  • Hemothorax

  • Pneumothorax

  • Catheter-related thrombosis (which may lead to pulmonary embolism)

  • Air embolism

  • Dysrhythmias

  • Atrial wall puncture from guide wire (which may lead to pericardial tamponade)

  • Lost guide wire

  • Anaphylaxis

  • Chylothorax (possible with left-side lead insertion)

A study by Armaganijan et al reported that age is a factor in early postimplant complications, with elderly patients (older than 75 years) having an increased risk of pneumothorax and both atrial and ventricular lead dislodgement/loss of capture. [17]

Late access-related complications include the following:

  • Chylothorax

  • Hematoma

  • Venous thrombosis or occlusion

  • Phlebitis

  • Atrioventricular fistula

  • Hemothorax

  • Infection

Pocket-related complications

Early pocket-related complications include the following:

  • Swelling

  • Hematoma

  • Bruising and local pain

  • Infection

Late pocket-related complications include the following:

  • Pocket erosion

  • Pocket infection

  • Chronic pain at the site

Lead-related complications

Early lead-related complications include the following:

  • Atrial or ventricular arrhythmias

  • Chamber perforation [18]

  • Pneumothorax and pneumopericardium (with an atrial lead)

  • Intercostal or diaphragm pacing

  • Pectoral muscle stimulation

  • Lead dislodgement

  • Tricuspid valve laceration

  • Cardiac tamponade

  • Pericardial friction rub

  • Hypotension

  • Bleeding

Late lead-related complications include the following:

  • Infection of pacer lead

  • Endocarditis

  • Systemic infection

  • Perforation

  • Access vein thrombosis

  • Inferior vena cava thrombus

  • Pectoral muscle stimulation

  • Right atrial thrombus

  • Loss of capture and sensing

  • Tricuspid regurgitation (also independently associated with body mass index >30 kg/m2 [19] )

  • Lead fracture

  • Intercostal or diaphragm pacing

Pacemaker generator–related complications

Early pacemaker generator – related complications include the following:

  • Infection

  • Malfunction, including undersensing, oversensing, loss of capture, loss of output, inappropriate rate, inappropriate mode, pulse generator failure, pacemaker-mediated tachycardia, and pacemaker syndrome [20]

Late pacemaker generator – related complications include the following:

  • Twiddler syndrome

  • Pacemaker infection

  • Pacer malfunction [20]

  • Allergy or sensitivity to the device materials

Pacemaker device infection

Cardiac device infections can lead to longer hospital stays, increased costs, and higher mortalities. If they are detected and treated at an early stage, device extraction may be avoided and patient morbidity and mortality significantly reduced.

Pacemaker infections may be divided into 2 general types on the basis of the initial source of infection:

  • Primary infections - The device or pocket itself is the source of infection, usually because of contamination at the time of implantation

  • Secondary infection - The leads, device, and the pocket are seeded by bacteremia derived from a different source

Overall device infection rates range from 0.68-2.2%. [21, 22, 23, 24, 25] Independent risk factors for cardiac device infection have been identified. These include the following:

  • Pulse generator replacement

  • Dual- or triple-chamber device implantation [22]

  • Advanced patient age (older than 60 years) [25]

  • Renal dysfunction

  • Oral anticoagulation [24]

Complete device system extraction (either percutaneously or intraoperatively), antimicrobial therapy of appropriate duration, and reimplantation of a new pacing system at a different site are the current methods of treatment for device infection. Implantation of a leadless permanent pacemaker lead (Micra, Medtronic Inc) may be preferable in some infected patients. The majority of patients discharged after such treatment will be free of infection. [26]

Other complications

The patient may experience reactions to either a local anesthetic or an IV sedative. Radiation skin burns have been reported to occur as a result of prolonged fluoroscopy in technically difficult cases.


Cardiac Resynchronization Therapy

Cardiac resynchronization therapy (CRT), also referred to as biventricular pacing or multisite ventricular pacing, is a component of modern heart failure therapy for qualified patients. In CRT, there is a coronary sinus lead for left ventricular epicardial pacing in addition to a conventional right ventricular endocardial lead. By simultaneously pacing the right and left ventricles, CRT reduces the ventricular dyssynchrony that is frequently present in patients with ventricular dilatation or conduction system defect.

CRT can involve either solely pacing (CRT-P) or also include the potential for defibrillation (CRT-D). The following discussion focuses on CRT-P.

CRT is recommended for patients with a left ventricular ejection fraction < 35%, a QRS duration longer than 120 msec, sinus rhythm, and New York Heart Association (NYHA) functional class III or ambulatory class IV heart failure symptoms with optimal medical therapy. [7] Trials suggest that CRT may also reduce morbidity and mortality in patients with mildly symptomatic heart failure. Consequently, the 2010 European guidelines and updated 2012 ACC/AHA/HRS guidelines now recommend CRT for the NYHA class II patient population. [27, 28] The ACC/AHA/HRS guidelines also now indicate CRT for patients with left-bundle-branch block with a QRS duration that is greater than or equal to >150 msec. [28]

Biventricular pacing has been effective in improving symptoms and quality of life, reducing heart failure hospitalizations, and reducing mortality because of its ability to achieve the following results:

  • Reduction in ventricular electromechanical delay

  • Improved ventricular function

  • Reduced metabolic demands

  • Improved functional mitral regurgitation

  • Favorable ventricular remodeling

  • Reduction of cardiac chamber dimensions

  • Improved exercise capacity

Factors that influence the responsiveness of patients to CRT or that are used to identify patients who will be responsive to CRT include the following:

  • QRS complex duration

  • Ventricular dyssynchrony (by echocardiography)

  • Successful lead placement

  • Physiologic atrioventricular delay

CRT requires left ventricular lateral wall pacing, which is achieved by placement of an epicardial lead via the coronary sinus. Multiple-guide catheter systems are available for coronary sinus cannulation, with most designs favoring a left pectoral approach. Coronary sinus phlebography facilitates placement by demonstrating vessel size, position, and angulation. Left anterior oblique and right anterior oblique projections are obtained with cine recording during injection of 10-15 mL of contrast in the coronary sinus.

A guide wire is inserted through the catheter positioned in the coronary sinus and maneuvered to the target venous branch. The coronary sinus lead is advanced over the guide wire into the desired branch of the coronary venous system.

The guide wire and guide catheter are withdrawn, leaving the coronary sinus lead in place. After acceptable thresholds and impedance are ensured, the lead is secured to the pectoralis with a nonabsorbable suture.

Identifying ideal sites for biventricular pacing has proven elusive when the criteria of latest epicardial activation, cumulative biventricular-paced QRS width, and empiric placement on the posterolateral wall are employed. Micromanometer recordings of the first derivative of left ventricular pressure (dP/dt) and 3-dimensional echocardiographic wall motion analysis provide superior information regarding lead site placement, but they are not widely used in clinical settings.

Frequently encountered difficulties include problems in cannulating the coronary sinus, acute angulation of the target venous vessels, and the absence of suitably sized veins in the left ventricular pacing region of interest. Right pectoral positioning of the biventricular pacing leads is more difficult in the presence of right subclavian–superior vena caval angulation and frequently requires the use of a deflectable guide catheter.