Pediatric Pacemaker Implantation Technique

Updated: Oct 25, 2017
  • Author: Bradley C Clark, MD; Chief Editor: Stuart Berger, MD  more...
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Approach Considerations

Provide a thorough and adequate explanation of pacemaker implantation procedures to the patient and family members. Document the 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
  • 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 the 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 placed in the right atrium or ventricle. Testing is performed using cables connected 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. The choice between a subcutaneous and submuscular pectoral pocket is operator-dependent. The submuscular pocket may create a better cosmetic result and be less prone to trauma, but there are risks related to difficult reoperation and increased bleeding with subsequent procedures.

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. [35]

This radiograph depicts a transvenous ventricular This radiograph depicts a transvenous ventricular pacemaker in 2-year-old child. Note the abundant slack in the 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 the epicardial sites to the pocket.

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

Aside from several weeks of 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/signs of possible infection.

For patients with newly implanted cardiac resynchronization therapy (CRT) devices, clinicians may choose to optimize the system (specifically the pacemaker timings) with the help of echocardiography (tissue Doppler imaging and speckle-tracking). A study has shown no difference in clinical outcomes between electrocardiography and echocardiography optimization of CRT in pediatric patients, although further study is ongoing. [36]



Complications of pacemaker implantation involve the immune response to artificial materials and the body's response 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.

Risk factors for complications related to epicardial pacemakers in neonates and infants include young age (37</ref> In addition, the development of pacing induced ventricular dysfunction (PIVD) in children receiving dual-chamber pacemakers for complete heart block following congenital heart surgery appears to be influenced by the underlying structural heart defect. One study comprising 47 children younger than 2 years who developed postsurgical complete heart block noted an association in nine children between PIVD with double outlet right ventricle, transposition of the great arteries (TGA) with ventricular septal defect, atrioventricular canal defect, mitral valve replacement, and congenitally corrected TGA, but not with tetralogy of Fallot alone, ventricular septal defect alone, atriventricular canal defect with tetralogy of Fallot, or subaortic membrane. [38]

A rare complication following epicardial pacemaker implantation is cardiac strangulation, which may be associated with a lack of consistent imaging for the diagnosis. [39]  Close monitoring of lead placement and close follow-up in patients aged 6 months or younger at the the time of implantation is advised. [39]  

Pacing leads are more prone to failure, particularly in children. [40] 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, administration of 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. [41] 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. [42]