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ARRHYTHMIAS
Permanent pacemaker implantation
technique: part I
Kim Rajappan
c Supplemental video footage is Although device therapy is increasingly a subspeci-
available online only at http:// alty in its own right, permanent pacemaker (PPM)
heart.bmj.com/content/vol95/
issue3
implantation remains one of the core skills of
cardiologists. Most trainees will require at least
basic skills in PPM implantation and the aim of this
Correspondence to: article (in two parts) is to provide a guide to the
Dr Kim Rajappan, Cardiac steps involved, and some of the fundamentals of
Department, John Radcliffe technique. No article on this subject can be totally
Hospital, Headley Way,
Headington, Oxford OX3 9DU, comprehensive and cover all the subtle nuances of
UK; kim.rajappan@orh.nhs.uk technique used by different operators.
Furthermore, like any practical skill it is only
possible to give a flavour of the methodology in
writing, and nothing can replace the practical
tuition of an experienced implanter in the pacing
theatre during a number of PPM implants. That
having been said, before outlining some of the
practical aspects of PPM implantation, the first
step is to identify whether a patient needs a PPM.
This may be straightforward, but there can be
some complex cases. For this information the
reader is referred to the various guidelines widely
available.1–3 When it comes to the actual implant
the following provides a step-by-step account.
PATIENT PREPARATION
For any patient undergoing PPM implantation,
appropriate informed consent should first be
obtained. This includes the indication for implan-
tation (often to prevent syncope secondary to
bradycardia) and the risks associated with the
procedure (table 1), which may be tailored to one’s
own practice/institutional figures; also it is increas-
ingly important to document other important
Table 1 Risks associated with permanent pacemaker implantation
Superficial bruising: common and of no clinical significance unless it leads to pocket haematoma
Pocket haematoma: often managed conservatively, but may need intervention depending on size,
concomitant anticoagulation, and/or tension on incision
Pneumothorax: risk depends on access route (table 2), but consent for 1% on average
Lead displacement: early and late displacements may be up to 4% in total
Cardiac perforation/tamponade: uncommon with current lead designs (,0.2%)
Infection: may be ,1% overall but recognised factors affect the risk* as below
Risk factor for infection OR (95% CI)
Fever within 24 h before device implantation 5.83
Use of temporary pacing wire before implantation 2.46
Pre-discharge re-intervention (eg, for clot evacuation, lead dislodgement) 15.04
De novo device implantation 0.46
Antibiotic prophylaxis 0.40
CI, confidence interval; OR, odds ratio.
*Adapted from Klug D, et al for the PEOPLE Study Group. Risk factors related to infections of implanted
pacemakers and cardioverter-defibrillators. Results of a large prospective study. Circulation 2007;116:1349–55.
Heart 2009;95:259–264. doi:10.1136/hrt.2007.132753
Education in Heart
information given to the patient—for example,
rules regarding driving.4 Placement of an intra-
venous cannula is routine for administration of
prophylactic antibiotics, administration of intra-
venous analgesia/sedation, and potentially to per-
form venography (see section on central venous
access techniques). For this latter reason it is the
author’s practice to make this at least a 20 G
cannula in the left antecubital fossa (assuming a
left sided implant) to allow adequate contrast flow
to visualise the venous anatomy. Pre-procedure
sedation may be given before the patient is moved
to the operating theatre, but if sedation is used at
all, it is often simply given in the theatre itself.
Most PPMs are implanted on the left side. This is
because it is more natural for right handed
operators and it is easier to position the leads
(especially the atrial lead). There may be good
reason to implant on the right side—for example,
the patient recently had an infected system
removed from the left—but handedness is not a
determining factor (although 90% of patients are
right handed anyway).
The choice of sedation and antibiotic prophy-
laxis will often be determined by local guidelines/
practice. It is of interest (and will no doubt be
recognised by all implanters) that there is a distinct
lack of either national or international guidance in
this latter area. This mainly stems from the
conflicting evidence regarding its use; however,
meta-analysis does suggest a benefit from pre-
procedure intravenous antibiotics.5 In general
protection against staphylococcal organisms is
required whichever antibiotic is used, and local
microbiological advice is often helpful to ensure
adequate cover against identified pathogens. In
most cases this will be either a single dose of a
penicillin-type antibiotic—for example, flucloxacil-
lin 1–2 g or a cephalosporin given within 2 h before
the implant itself—but vancomycin and gentami-
cin are increasingly used in cases that are deemed
to be higher risk—for example, in patients with a
recent, unrelated infective illness.
Preparing the procedure field is also crucial to
minimising complications. Sterility is obviously of
(2.00 to 16.98)
paramount importance, and the technique for this
(1.09 to 5.13)
is best learnt from an experienced scrub nurse. Of
(6.7 to 33.73)
note, some units will use disposable drapes that are
(0.24 to 0.87)
(0.18 to 0.86)
pre-fashioned, while others retain conventional re-
usable drapes. Whichever is being used, the
operator needs to ensure that these are placed in
a position that enables them to access all parts of
259
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Education in Heart
Figure 1 In panel A the position of three common incisions are shown in relation to the
clavicle and humeral head. Deltopectoral (DP) incision—ease of access to the cephalic
vein but may limit access to the subclavian vein. The operator needs to ensure the pocket
is made medially to the incision; it may be more difficult to make a subpectoral pocket
with this incision. Horizontal (H) incision—ease of access to both the cephalic and
subclavian veins with this incision, although not as easy for the cephalic vein as the
deltopectoral incision. It can be used for either subcutaneous or subpectoral pocket
formation. Oblique (O) incision—similar to the horizontal incision but parallel to Langer’s
lines. It can make access to the cephalic vein more difficult. Incisions parallel to these
lines may cause less scarring and give a better cosmetic result. In panel B the sterile
drapes are in place, and the locations of the three incisions are shown again.
the field that they desire (fig 1). Movement of
these drapes during the procedure should be kept
to an absolute minimum, and if possible avoided
altogether. Some operators will use a transparent
adhesive dressing over the operation field to assist
in holding the drapes in position, as well as
maintaining skin tension.
EQUIPMENT
Apart from the fluoroscopy equipment and vital
observation monitors—for example, automated
Figure 2 Pacing trolley laid out with instruments and
equipment before permanent pacemaker implantation.
These include: (A) a selection of scissors, (B) self
retainers, (C) sterile cover for image intensifier, (D) sterile
pots for cleaning solution, saline, (E) gauze, (F) selection
of sutures, (G) lead testing cables, (H) toothed and non-
toothed forceps, (I) skin preparation swabs, (J) selection
of clips, and (K) suture holder.
260
blood pressure cuff and oxygen saturation
probe—there are a number of sterile surgical
instruments and equipment that are needed.
Figure 2 shows a standard PPM trolley set up for
implantation. The quality of the instruments is
important in determining the ease and speed of the
procedure, and where necessary inadequate equip-
ment should be replaced.
INCISION
There are at least three different recognised
incisions that are used for PPM implantation
(fig 1). Most operators will develop a preference
for one of these or a slight variation on them. Each
of them has advantages and disadvantages (shown
in fig 1) and the way in which the incision is made
can again determine the ease of implant. A poorly
made incision can hamper access to the vein, make
fashioning the pocket problematic, and potentially
lead to a poor cosmetic result. For the ‘‘deltopec-
toral’’ incision, the incision is made from approxi-
mately 1 cm below the clavicle, in the delto-
pectoral groove (indentation between the clavicu-
lar head of the pectoralis major medially and the
deltoid laterally). For the ‘‘horizontal’’ incision the
cut is made starting approximately 1–2 cm below
the junction of the middle and lateral thirds of the
clavicle and extending directly laterally to cross the
deltopectoral groove by approximately 1 cm. The
‘‘oblique’’ incision is made running parallel to and
approximately 1–2 cm below the lateral third of
the clavicle. The total length of the incision
(commonly 4–5 cm) will vary according to: (1)
the size of the device; and (2) the thickness of the
subcutaneous layer (a longer incision is required if
thicker tissue is present). Before performing the
incision, local anaesthetic is infiltrated along the
length of the intended incision as well as more
deeply and slightly medially in preparation for the
PPM pocket formation. Although guidelines sug-
gest a maximum 3 mg/kg of 1% lignocaine (so in a
50 kg person this is only 15 ml), more may need to
be used to achieve adequate anaesthesia.
POCKET FORMATION
Although the pocket may be formed in the axilla
(in children in particular) or in the abdomen (for
epicardial or femoral systems), the most common
site is the pectoral region. Debate exists about
some aspects of PPM pocket formation. The first is
whether to fashion a subcutaneous pocket (at the
level of the prepectoral fascia), or submuscular
pocket (this could be either an intramuscular
pocket between the pectoralis major and minor,
or a subpectoral pocket below both the pectoralis
major and minor and above the ribcage). The
subcutaneous pocket is the easiest and least painful
to form, although it is imperative to get into the
correct plane of prepectoral fascial tissue. Once in
the correct plane, the pocket is made simply by
using one or two fingers to gently spread the
tissues apart slightly medially and caudally, after
infiltration of local anaesthetic; note that in a
Heart 2009;95:259–264. doi:10.1136/hrt.2007.132753
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Table 2 Advantages and disadvantages of different venous access routes
Subclavian Extrathoracic
Cephalic vein vein subclavian/axillary vein
Surgical skill required Most skill needed Average Average
Pneumothorax risk ,0.1% 1–2% ,0.1%
Risk of lead crush Very low Highest Low
Amount of fluoroscopy required to gain Minimal Minimal More than other 2
access methods
Ease of passage of multiple leads May be difficult Easier Easiest
Ease of extraction if required May be difficult Easier Easier
young, muscular patient this tissue plane may still
be fairly tight and require some effort to separate
the layers, whereas in a more elderly patient it
often spreads apart with minimal pressure. The
submuscular pockets are formed by a shallow
incision in the pectoralis major muscle and then
blunt dissection, either through both muscle layers
(subpectoral) or just down to the pectoralis minor
(intramuscular, although this plane can be quite
difficult to identify). This is more painful than
subcutaneous pocket formation, but can be done
with conscious sedation.6
With the size of current devices the subcuta-
neous pocket is sufficient for the vast majority of
people undergoing PPM implantation; however, for
those with little adipose tissue the submuscular
pocket offers increased protection against device
erosion. Other perceived advantages of a subcuta-
neous pocket are that generator changes are easier
and there is less risk of neurovascular damage
when forming the pocket than if one dissects
through the muscle, while submuscular pockets
give a better cosmetic result and reduce the risk of
migration. In reality, there are little definitive data
to support any of these suggestions and ultimately
the choice of pocket will lie with the operator, or in
Figure 3 In panel A the cephalic vein has been isolated with silk ties at either end, and
is lifted up by a clip to demonstrate it more clearly. The location of the deltopectoral
groove in relation to this has been marked. In panel B, after an incision was made with
iris scissors, the vein lifter (inset) has been used to open the cephalic vein lumen and a
pacemaker lead has been inserted.
Heart 2009;95:259–264. doi:10.1136/hrt.2007.132753
Education in Heart
some cases with the patient (either through patient
choice or because of the body habitus).
The pocket may be fashioned at the start of the
procedure before any lead placement, or at the end
once the leads are secured (see section on lead
placement techniques in part II). There are some
specific reasons why the pocket may be made later
in the procedure. If an axillary or submuscular
pocket is being used it may be easier to gauge the
final optimal position of the pocket after securing
the leads. In routine practice the advantage of
making the pocket (particularly a subcutaneous
one) early in the procedure is that there is less
chance of inadvertently displacing the leads once
they are in place. The disadvantage is that there is a
small chance that venous access will be impossible
on the ipsilateral side and a redundant pocket then
exists. However, this finding is relatively rare and
therefore most operators will make the pocket
early in the procedure.
CENTRAL VENOUS ACCESS TECHNIQUES
This fundamental step can be broadly divided into
those techniques involving direct visualisation of
the target vein by a cut down technique (most
commonly the cephalic vein), or those involving
needle puncture of the vein.7 Advantages and
disadvantages of each are shown in table 2.
Cephalic vein cut down
The usual course of the cephalic vein is in the
delto-pectoral groove, penetrating the clavi-pec-
toral fascia to join the axillary vein medial to the
pectoralis minor muscle. An occasional variant
runs over the superficial surface of the clavicle to
join the external jugular vein. When dissecting in
the groove towards the lateral border of the
pectoral muscle it is common to see an area of
adipose tissue caudal to the lateral end of the
clavicle. Dissection through this tissue, between
the pectoralis major muscle on the medial side and
the deltoid muscle on the lateral side, may reveal
the cephalic vein at the bottom. It is worth noting
that sometimes it lies just under the edge of the
muscle so it is important to explore the margins
carefully. Once the vein has been identified it is
freed from the surrounding tissue by careful
dissection. Ideally a 1–2 cm length of vein needs
to be freed. An accompanying arteriole is common
and one should be alert to this, carefully dissecting
the vein away and ensuring cannulation of the
correct vessel. Also, there may be a plexus of veins
rather than a single vein. In this case it may be
possible to cannulate the largest branch, but if they
are all of similar small calibre it may be better not
to attempt this route. The vein may lie deep, and
the difficulty this creates may again mean that the
operator does not pursue this access route,
particularly in patients with a large body habitus.
Once the vein is freed it is tied off at the distal end
(farther away from the patient and closer to the
operator). Care needs to be taken not to twist the
vein as this is done because this makes venotomy
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Education in Heart
Figure 4 A venogram has been performed from the left antecubital fossa (top panel).
This shows the drainage into the cephalic vein, axillary vein, running over the first rib, and
then into the subclavian vein. A schematic is shown in the lower panel outlining the
important structures and landmarks for an extrathoracic subclavian/axillary vein puncture.
The area in red represents the target area for puncture of the vein in an extrathoracic
position, theoretically making the risk of a pneumothorax almost zero.
and passage of a guide wire or lead more difficult. A
loose tie is left on the cephalic vein proximal to
where the venotomy incision is made. Sharp, fine
scissors should be used for the venotomy (iris
scissors). The vein is then entered using a vein lifter
(fig 3). The lead(s) may be directly passed through
the cephalic vein or guidewires can be introduced
and sheaths used. When passing a guidewire it may
track into the axillary vein (down the arm) rather
than the subclavian. If this happens, pull back the
guidewire to the entry point of the cephalic vein
into the axillary vein and manipulate it directly
into the subclavian vein under fluoroscopy.
Traction on the patient’s ipsilateral arm may
lessen the angle of entry and facilitate this process.
Where valves obstruct passage of the lead itself a
standard guidewire, or a hydrophilic guide wire (for
example, Terumo), may help. Tortuosity of the
cephalic vein can normally be negotiated by the use
of one or more of these techniques.
Subclavian vein puncture
This route is the first choice access for some
operators, particularly if an extrathoracic approach
is used. For the conventional percutaneous sub-
clavian puncture to insert a central access catheter,
for example, the landmark for entry through the
skin is the junction between the medial and middle
third of the clavicle. When performing a subclavian
puncture during PPM insertion it needs to be noted
262
that puncture is no longer being made through the
skin and subcutaneous tissue but now directly
through the muscle. This means that although the
entry point through the muscle is similar, the angle
of the needle to the chest wall has to be reduced—
that is, the needle is less steep to allow for the fact
that entry is up to several centimetres below the
skin surface in some individuals. Once the muscle
is pierced the needle is advanced from a lateral to
medial direction aiming for the medial head of the
clavicle. Some operators describe ‘‘walking under’’
the clavicle—this means that the needle is kept
horizontal and when advancing the needle the
clavicle is hit and then the needle is retracted
slightly, the angle of the needle slightly steepened
and the needle advanced again. This process is
repeated until the needle just passes under the
clavicle. This reduces the risk of inadvertent lung
puncture but may increase the risk of damage to
the inserted pacemaker lead from pressure of the
clavicle (‘‘subclavian crush’’).
Although some operators perform this puncture
without any form of extra imaging, the fact that
the subclavian often runs under the medial head of
the clavicle means that fluoroscopy can be used to
help guide the needle (fig 4). An extrathoracic
subclavian vein puncture is performed over the
first rib. The puncture through the muscle is made
slightly more medially than the conventional
subclavian puncture, but importantly the angle of
the needle is much steeper (in some cases almost
90u) and it is advanced in a superficial-to-deep and
anterior-to-posterior direction. This is done under
fluoroscopy and it is important that the needle
always remains over the first rib in the standard
postero-anterior (PA) projection, and specifically
never passes medial to the rib (fig 4). The needle is
advanced (gently aspirating on an attached syringe
as with any other indirect puncture), aiming for
the space below the clavicle and over the first rib
until either the vein is cannulated or the rib is
struck (supplemental video 1). If the rib is struck
the needle should be gently withdrawn 1–2 cm
while still aspirating and, if there is still no
flashback of blood, the caudo-cephalad angle of
the needle is changed to aim for either a slightly
more cephalic or caudal position on the first rib and
the same process repeated. The steep angle of the
needle may mean the vein collapses on the needle,
making passage of the guidewire difficult.
Other access sites
Axillary vein puncture is performed by cannulating
the vein over the second rib. Usually a venogram is
performed to help guide puncture as the course of
the axillary vein is more variable than the
subclavian vein (fig 4, supplemental video 2).
This technique is described in more detail else-
where.8 The internal jugular vein and femoral vein
may also be used in certain circumstances, but
neither of these is used routinely as the first choice
for lead implantation and is reserved for cases
where the other access sites are not possible.
Heart 2009;95:259–264. doi:10.1136/hrt.2007.132753
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Permanent pacemaker implantation I: key points
c Documentation of consent and any advice given to the patient before
permanent pacemaker implantation is essential.
c Be meticulous over aseptic technique from start to finish.
c A poorly made incision can affect the entire procedure.
c Where access is proving difficult, perform a venogram and consider
manoeuvres to increase venous filling.
Troubleshooting difficult central access
As with axillary vein puncture, where it is proving
difficult to cannulate the subclavian vein it is often
worth performing a venogram from the ipsilateral
arm (usually through a cannula in the antecubital
fossa) to delineate the exact course of the vein over
the first rib and under the clavicle (fig 4, supple-
mental video 2). Also, with patients in a sedated state
and having often been left relatively dehydrated
before the implant procedure, it may be worth giving
fluid intravenously to increase central venous filling,
and using a wedge under the legs as well as head-
down tilt to increase venous return. Where there is
difficulty in passing the guidewire from the sub-
clavian into the superior vena cava (SCV), it is
possible to place the dilator from the introducer
sheath into the subclavian and inject contrast to
visualise this area clearly and look for obstruction/
stenosis, particularly where there are leads already in
the vein. If bleeding from the puncture site into the
pocket is a problem after the leads have been
positioned, a purse string suture around the leads
into the muscle and pocket can help.
Multiple lead access
Where access is required for more than a single
pacemaker lead, the operator has to make a
decision how to best achieve this. With the
cephalic vein, for example, it is theoretically
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Education in Heart
possible to provide unlimited venous access
through the venotomy. However, the size of the
vessel will limit this to some extent. Where the size
of the vein allows, some operators will simply pass
two (or more) leads via the cephalic vein without
any guidewires or sheaths. Alternatively two
guidewires may be positioned through the cephalic
vein into the subclavian vein. This is achieved by
passing an introducer sheath down the first guide-
wire, taking out the dilator from the sheath while
retaining the guidewire in the sheath, passing an
extra guidewire next to the existing one down the
introducer sheath, and then taking out the
introducer sheath without removing any of the
guidewires. Introducer sheaths are then used for
each lead in turn. With a dual chamber pacemaker
the right ventricular lead is conventionally posi-
tioned first, and then the right atrial lead. Friction
between adjacent leads can hamper manipulation
in this situation, causing inadvertent lead dislodge-
ment. To minimise interaction of the two leads,
while positioning the second lead the introducer
sheath may be left in situ until both leads are in a
satisfactory position. Where multiple access is
through a subclavian or axillary vein puncture a
similar ‘‘double wiring’’ technique may be used,
particularly if the puncture has been difficult and
the risk of a pneumothorax may be increased by
multiple attempts. However, there may be a
slightly increased risk of bleeding from the larger
hole created, so if the puncture is straightforward,
a second puncture should be performed, which also
makes individual lead manipulation easier.
This concludes the first part of this two part
article. In part II further aspects of the implant
process including lead placement techniques will be
considered.
Competing interests: In compliance with EBAC/EACCME guide-
lines, all authors participating in Education in Heart have disclosed
potential conflicts of interest that might cause a bias in the article.
The author has no competing interests.
REFERENCES
1. British Pacing and Electrophysiology Group. Recommendations
for pacemaker prescription for symptomatic bradycardia. Report of a
working party of the British Pacing and Electrophysiology Group. Br
Heart J 1991;66:185–91.
2. European Society of Cardiology, European Heart Rhythm
Association. The Task Force for Cardiac Pacing and Cardiac
Resynchronization Therapy of the European Society of Cardiology.
Developed in Collaboration with the European Heart Rhythm
Association. Guidelines for cardiac pacing and cardiac
resynchronization therapy. Eur Heart J 2007;28:2256–95.
3. Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008
guidelines for device-based therapy of cardiac rhythm abnormalities.
J Am Coll Cardiol 2008;51:1–62.
c The most recent guidelines on selection of patients for PPM
implantation. Importantly, these now emphasise the need
for the implanter to think carefully about each individual
patient’s case and the device used.
4. Driver and Vehicle Licensing Agency. For medical practitioners.
At a glance guide to the current medical standards of fitness to drive.
p19 http://www.dvla.gov.uk/media/pdf/medical/aagv1.pdf.
c Helpful information to give to patients, and should be
documented when given.
5. Da Costa A, Kirkorian G, Cucherat M, et al. Antibiotic prophylaxis
for permanent pacemaker implantation: a meta-analysis. Circulation
1998;97:1796–801.
c Meta-analysis of the limited number of randomised trials to
evaluate the effectiveness of antibiotic prophylaxis to
263
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Education in Heart

reduce infection rates after PPM implantation, which,
despite the limitations of some of the studies included,
demonstrated a benefit in the use of pre-procedure
parenteral antibiotics to prevent short term pocket
infection, skin erosion or septicaemia.
6. Lipscomb KJ, Linker NJ, Fitzpatrick AP. Subpectoral implantation
of a cardioverter defibrillator under local anaesthesia. Heart
1998;79:253–5.
7. Lau EW. Upper body venous access for transvenous lead
placement – review of existent techniques. Pacing Clin
Electrophysiol 2007;30:901–9.
c Comprehensive yet brief review of the techniques available.
8. Burri H, Sunthorn H, Dorsaz PA, et al. Prospective study of axillary
vein puncture with or without contrast venography for pacemaker
and defibrillator lead implantation. Pacing Clin Electrophysiol
2005;28:S280–3.

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264 Heart 2009;95:259–264. doi:10.1136/hrt.2007.132753

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Permanent pacemaker implantation

technique: part I
Kim Rajappan

Heart 2009 95: 259-264

doi: 10.1136/hrt.2007.132753

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