Overview of Pacemaker Implantation

Pacemaker Workshop Team

DI & INB PJN Harapan Kita
Jakarta
Pacemaker Implantation

Content:
Pre-implant preparation
Implantation procedure
- Incision and pocket creation
- Venous access and troubleshooting
- Lead placement and fixation
- Wound closure

Post-implant care
Pulse generator change
Special considerations
Pre-implant Preparation (1)

Indications

Employment, hobbies: Welder, shooting, etc

Patient information

What the procedure involves (risks)

Impact of a pacemaker in daily life

Inform consent
Pre-implant Preparation (2)

Fasting (ensure adequate iv hydration)

Ipsilateral peripheral catheter: contrast injection for venous access

Chest X-ray
- morphological anomalies?
- used later for comparison in case of suspicion of a pneumothorax

Skin preparation: shaving, antiseptic scrubs

Prophylactic antibiotics
- e.g. UNASYN 1.5 gr, 1 hour before the procedure
Pacemaker Implant

Cathlab
OR equipped with fluoroscopy

Basic surgical skill

Local anesthesia
Short procedure
C-arm fluroscopy

ECG monitor

Surgical instruments
Implantation Procedure

Preparation / Approach

Incision

Dissection

(Pocket creation)

Venous access

Lead placement & fixation

(Pocket creation)

Wound closure
Preparation

Patient comfortable on table

Use of adhesive defibrillator patches?
- risk of requirement for backup pacing (LBBB)
- high-risk patient (poor LVEF, heart failure)

Skin cleaning
- allow to dry

Draping : usually both side

- Allow for access to both sides (in case of venous access problems)

Sedation / analgesics (optional)

- e.g. midazolam 1-2 mg iv
- e.g. pethidin 0.5-1 mg/BB iv

Local anaesthesia
- e.g. Marcain 0.5 % 15-20cc sc
Pacemaker Implant Procedure

Venous access
Lead insertion and testing

Pocket formation and IPG implant

Approach

Pectoral

Right sided:
- shorter distance
- potential difficulties at angulation of subclavian and
SVC

Left sided:
- usually non-dominant side
- can be an issue with persistent left sided SVC
- may result in stenosis of the innominate vein

Axillary, sub-mammary
 Head
Feet

Delto-pectoral
groove
Dissection

Blunt dissection with scissors

Electrocautery; use only coag
Down to pectoralis major muscle
Clear view of deltopectoral groove
Treat bleeding points (electrocautery coag)
Horizontal vs vertical incision
Lead Insertion
Venous access
3 4
1 5
1.Subclavian 2
2.Cephalic
3.External Jugular
4.Internal Jugular
5.Axillary vein

6
Venous Access
 Cephalic vein cutdown

Valve
Cephalic vein cutdown
Cephalic vein cutdown
Cephalic vein cutdown
Cephalic vein cutdown
Subclavian vein puncture

Advantages
Quick (usually)
Disadvantages
Pneumothorax
Risk of subclavian crush
Friction with clavicle/musculotendinous
complex may hinder lead manipulation
Subclavian vein puncture

Level of puncture at ~ medial 1/3 of the clavicle

Use syringe half filled with saline or lidocain and aspirate while advancing the
needle
Direct needle parallel to the clavicle / towards suprasternal notch (green arrow)
Avoid excessive friction with the clavicle
Ipsilateral perfusion and Trendeleburg position will increase the size of the vein
Subclavian puncture

Avoid medial punctures

(usually of brachiocephalic vein):

- subclavian crush
- pneumothorax
- arterial puncture (non-compressible)
- tracheal puncture (hemoptysis)
 Subclavian venogram

Allows for more lateral access

Do if difficulties with blind
puncture
Do always in diagnosis of
stenosis
Venous canula in brachial vein
20 ml contrast (may be
semidiluted) then flush
Subclavian vein puncture
Axillary vein puncture
Anatomical considerations

Intrathoracic
subclavian

Axillary

Extrathoracic Inferior border

subclavian of 1st rib
 Axillary puncture: Technique

10-20cc bolus of semi-diluted contrast via ipsilateral peripheral venous catheter

Bolus saline then flush continuously to fill the vein
Puncture during venogram (blanching of vein may be seen before entry)
Advance then slowly withdraw needle while aspirating (vein may have been
traversed)

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Lead Implantation
Ventricular Lead Placement

Electrical parameters
Sensing > 4mV
Pacing < 1.5V/0.5ms

No diaphragmatic stimulation @10V

Tricuspid Kick
Active fixation leads:
Check for current of injury

May have high acute thresholds

(but usually < 2V/0.5ms)
check after 2-5min
Atrial lead placement

Place lead in mid-atrium

with straight stylet
Exchange to J-stylet and
withdraw to appendage
Check windscreen wiper
motion of the lead (if sinus
rhythm)
PA
RAO LAO
Active lead fixation
Lead Anchoring
IPG Implant
Pacemaker Attachment
 Connecting the lead to the generator

Clean off blood on the lead connector pin (may freeze the lead in
the connector block)

Do not kink the lead when pushing it into the connector block

Make sure that the pin is pushed as deep as possible in the connector
block (air pocket may hinder)

1 or 2 set screws, depending on pacemaker model

Use dynamometric wrench perpendicular to the silicone seal (avoid

damaging the seal risk of current leak with extracardiac stimulation)

Set distal screw first, and gently tug the lead to test
Placement of generator and leads in pocket
Pacemaker Attachment
Wound Closure

Suture of the generator to the pectoral

muscle with non absorbable suture is
optional
(except in cachectic patients and for ICDs)
Optional rinsing of pocket with Gentamycine
/ Povidone-Iodine (no proof that this
reduces risk of infection)

Aim to isolate pocket from wound

(muscle/fascia plane) Subcutaneous suture
draws wound together
Use absorbable sutures
(e.g.Monofyl/Vicryl: 3-0)

Subcuticular to finish
(e.g. Monofyl /Vicryl/Vicryl Rapide: 4-0)

Steristrips (optional)

Dressing
Lead Testing
Post Operative Care

Limited bed rest

Analgesia

Prophylactic antibiotics
(e.g. Unasyn 1.5 gr 2x/d for 48h)

Keep wound dry until healing

Opsite Post-Op dressing allows showers

Pre-discharge checks

Chest X-Ray

Pacing check and programming

Complications

Pocket haemotoma Infection

Pneumothorax Lead fracture

Insulation failure
Perforation leading to cardiac tamponade
Others
Lead dislodgement
Header issues
Patient Recovery

Resume daily activities and lead a normal life with

periodic pacemaker check-up
Pacemaker ID Card & Information

Pacemaker ID card
Pacemaker Programming & follow-up
 The importance of pacemaker
programming & follow-up

Pacemakers need to be checked periodically to

ensure that they are working properly
Pacemakers provide useful information for the
physician to manage the patient better
Pacemakers need to be programmed to tailor
therapy to the current condition of the patient
Pacemakers need to be monitored for remaining
battery life so that timely replacements may be
made
Patients must consult their doctor if they feel symptoms like fatigue, breathlessness, dizziness, near fainitng
or fainting
 Programming

Pacing Mode
Pacing Rate
Pacing output
Voltage
Pulse-width
Sensitivity
Setting
AV Interval
Rate
Responsive
Pacing
 Patient Follow-up

First follow-up: 1 weeks + 60/90 days post-

implant
Every 6 months to a year

Every 3 months as pacemaker reaches end of life

Potential Problems with Pacemakers

Battery Depletion
Lead displacement or perforation
Loss of capture and/or sensing
Lead fracture or insulation break
Loss of capture and/or sensing
Increase in thresholds due to
Drugs
Electrolyte imbalance
Interference from external electromagnetic sources
Device malfunction
Routine Follow-up
Patient Status
Symptoms/complaints
Disease progression
Medication changes
Pacemaker System Integrity
Battery Voltage
Lead impedances
Capture threshold testing
Sensing R wave & P wave Amplitudes
Appropriateness of Programmed Parameters
Diagnostic information about patients arrhythmia status
Heart rate profile
Atrial arrhythmia
Ventricular arrhythmia
AV conduction status
 Pacemaker Follow-up

All the Information for Routine Follow-ups

Operating
Mode

Last Interrogation
Longevity

A&V Pacing Arrhtymia

Thresholds Summary

% Pace/Sense
Histograms
A&V Pacing
Lead Alert of situations
Impedance that may require
further
P&R wave investigation
Amplitudes
Magnet Operation

Varies across manufacturers and models

Medtronic Normal
- VOO, DOO mode 85 ppm
- No sensing, asynchronous pacing
Medtronic ERI VOO, DOO mode 65 ppm
Special Precautions EMI
General Principle
Avoid proximity to powerful electric or magnetic fields
Move away from the field if symptomatic
Keep safe distance 6 inches for electrical appliances
Safe from Interference
Microwave, TV, Washing Machine, Fridge, Vacum cleaners etc.
Cordless phones
Computer, printer, scanner, photcopier
Possible interference
Items with large magnets, e.g. speakers, car ignition systems
Hand-held hair dryers
Radiotransmitters
Cellular Phones
Special Precautions Medical
Procedures
Safe Medical Procedures
Dental Procedures
Diagnostic X rays, CT scan
Ultrasound
Medical procedures requiring special care
Lithotripsy
Radiation therapy
Procedure requiring Cautery
Diathermy
TENS
External Defibrillation
MRI is contraindicated
 Special Precautions EMI

Industrial Equipment

Large generators, motors, transformers

Arc welding
Power Transmission lines

Your Medtronic representative can provide you with specific precautions for specific types of equipment
Pacemaker Replacement

7 to 14 years
ERI Elective Replacement Indicator

3 months pacemaker life remaining

Entire pulse generator to be replaced
Leads may be retained
Mommy..Im Confuse.!!!