Valve Repair / Replacement Surgery
June 11, 2019
RIRS
June 11, 2019
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Pacemaker Implantation

Pacemaker implantation

 

Although device therapy is increasingly a subspecialty in its own right, permanent pacemaker (PPM) 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 article (in two parts) is to provide a guide to the steps involved, and some of the fundamentals of technique. No article on this subject can be totally comprehensive and cover all the subtle nuances of 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.13 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 implantation (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 increasingly important to document other important information given to the patient—for example, rules regarding driving.4 Placement of an intravenous cannula is routine for administration of prophylactic antibiotics, administration of intravenous analgesia/sedation, and potentially to perform 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 …

LEAD PLACEMENT TECHNIQUES

Before discussing lead placement itself, it is important to briefly explain the structure of a permanent pacing lead. The leads themselves are very floppy and intrinsically have very little stiffness. This means that as the lead is moved around, the tip moves freely without any significant ability to steer it. To overcome this there is a central lumen to the lead which will allow passage of a stiffer thin wire known as a “stylet”. The further the stylet is passed down the lead (potentially almost to the tip), the more of the lead body is stiffened (fig 1). These stylets may also be “reshaped” easily to allow the tip of the lead to be further steered in a specific direction (fig 1). It is important to keep this stylet clean and free of debris, particularly blood, as this can block the central lumen and prevents the stylet from passing far enough down the lead to give any useful support. Also, the different lead positioning techniques described below are not mutually exclusive. A competent operator will be comfortable with most of them to adapt to different situations, although they may have a preference for which one they use first. The fixation method of the lead also has important implications. Lead tips may fixate “passively” or “actively”. Passive fixation leads have “tines” at the end of the lead (fig 1) which act as an anchor to hold the lead tip in place acutely. Over a period of time (weeks to months) the tip of the myocardium around the lead …

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