Permanent pacemaker insertion. 1. Introduction

Currently available permanent pacemakers contain a pulse generator and one or more pacing leads. Early in the era of pacemaker implantation, this procedure was only performed by the cardiac surgeons because of the initial mandate for epicardial lead implantation. Further advancements in the pacing hardware and percutaneous venous catheterization simplified the implantation technique and made it feasible to implant the transvenous leads. Simultaneously, further innovations in the pulse generator and its circuitry extended the utility of the percutaneous technique even in the very young patients. All device trainees will require basic skills in pacemaker implantation.

After the procedure In the hospital After Perkanent procedure, you may be taken to the recovery room for observation or returned to your Permanent pacemaker insertion Permaneht. A blow to the chest near the pacemaker can affect its functioning. Note that although an MRI is a very safe procedure, the magnetic fields used by the MRI scanner may interfere with the pacemaker's function. Related Topics Cardiovascular Arrhythmia Treatment. An incision is made in the chest where the leads and pacemaker are inserted.

Permanent pacemaker insertion. DISCHARGE INSTRUCTIONS:

The lead delivers the electrical Amateur thongs free to the heart. The indication for pacing pacemakfr be thoroughly described to the patient. Before pacemaker implantation, an informed consent should be obtained. The nature of your occupation, your overall health status, and your progress will determine how soon you may return to work. A sterile bandage Permanent pacemaker insertion dressing will be applied. Always consult your Permanent pacemaker insertion when you feel ill after an activity, or when you have questions about beginning a new activity. Will I be monitored? The epicardial approach is a less common method in adults, but more common in children. Can I drive myself home? Once the leads have been tested, the doctor will connect them to the pacemaker.

You will receive an instruction sheet that describes how to prepare for the procedure.

• Pacemakers are commonly used to treat patients whose heart beats too slowly, but can also be used to regulate an abnormally high heart rate or to treat severe heart failure.
• A pacemaker insertion is the implantation of a small electronic device that is usually placed in the chest just below the collarbone to help regulate slow electrical problems with the heart.

Currently available permanent pacemakers contain a pulse generator and one or more pacing leads. Early in the era of pacemaker implantation, this procedure was only performed by the cardiac Permanent pacemaker insertion because of the initial mandate for epicardial lead implantation. Further advancements in the pacing hardware and percutaneous venous catheterization simplified the implantation technique and made it feasible to implant the transvenous leads.

Simultaneously, further innovations in the pulse generator and its circuitry extended the utility of the percutaneous technique even in the very young patients. All device trainees will require basic skills in pacemaker implantation. However, first step is to identify whether a patient needs a permanent pacemaker. This chapter will summarize the necessary equipments, patient preparation, and implantation techniques.

Like any practical skill it is only Peranent to give a flavor of the methodology in writing, and nothing can replace the practical tuition of an experienced implanter in the pacing theatre during a number of pacemaker implants. The pacemaker implantation can be performed in electrophysiology EP laboratory, catheterization laboratory, or operating room [ 1 ]. Pacemaker implantation by interventional electrophysiologist in EP lab or catheterization laboratory resulted in a significant reduction in medical cost and hospital stay [ 2 ].

Minimum required personnel for pacemaker implantation consist of implanting physician, scrub nurse, and circulating nurse or technician. Scrub nurse is required to help the implanter throughout the procedure. The circulating nurse or technician is required to prepare and administer medications, and to operate pacing system analyzer.

Fluoroscopy and pacemxker ECG are necessary equipments in every device implant. Currently, initial lead sensing and capture measurements are obtained by pacing system analyzers Figure 1which may be stand-alone or built into the pacer programmer. Permaneent from the fluoroscopy equipment and vital observation monitors, there are a number of sterile surgical instruments and equipment that are needed Figure 2.

Suture materials include both nonabsorbable material for lead and device anchoring and absorbable material for pocket closure. Antimicrobial flush and pacemaked for pocket irrigation should be available. If venography is to be performed, an appropriate intravenous contrast agent must be available.

Before pacemaker implantation, an informed consent should be obtained. The indication for pacing should be thoroughly described to the patient. The need for lifelong follow-up should be emphasized and patient should be informed about the generator change and possible lead replacement in the future. Any physical or occupational restrictions related to the pacemaker implantation including rules regarding the driving should be discussed in detail with the patient.

Routine pre-implant lab tests are lead ECG, chest x-ray, complete blood count, prothombin and partial thromboplastin times, serum electrolytes, blood urea nitrogen, and serum creatinine.

Many of the patients requiring a pacemaker may be on oral anticoagulant [ 3 ]. Perioperative management of these patients is often challenging and Blondie pornstars special experience.

In the past, standard practice was to discontinue warfarin 48 hours before the procedure, Permaneht with intravenous heparin, and then reinitiate warfarin the day of the procedure or even the night before. Recently, there has been an Perrmanent interest in performing the pacemaker implantation without reversal of the anticoagulant.

This practice was associated with lower risk of pocket bleeding and shorter hospital stay [ 35 - 7 ]. Antibiotic prophylaxis is a controversial issue, but most implanters prefer to give oral or intravenous IV antibiotics to decrease the incidence of local or systemic infections based on limited data available [ 8 ].

Although there is a distinct lack of either national or international guidance in this area, meta-analysis of the randomized trials suggests a benefit Permanent pacemaker insertion pre-procedure intravenous antibiotics [ 9 ].

Our routine practice is to give 1 gram of cefazolin or vancomycin in penicillin-allergic Petmanent one hour before the procedure. Implantation of pacemaker usually involves a combination of local Permanent pacemaker insertion and conscious sedation.

However, to obtain optimal anesthesia, conscious sedation in the form of carefully titrated IV midazolam and fentanyl is recommended. Ibsertion rare occasions, general anesthesia may be required in an extremely uncooperative patient. Implant area from the angle of jaw to the nipple line bilaterally should be completely cleansed and shaved.

On entering the procedure room, the patient is usually placed on his or her back with the arms tucked and physiologic monitoring ECG, pulse oximetry, and noninvasive blood pressure should be quickly established to detect any arrhythmia or hemodynamic abnormality.

Preparing the procedure field is also crucial to minimizing complications. Sterility is obviously of paramount importance; 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. A central vein ie, the subclavian, internal jugular or axillary vein is accessed via a Permanent pacemaker insertion approach.

Alternatively, target vein is accessed via direct visualization by a cut down technique most commonly, cephalic vein. Figure 3 shows a standard prepackaged introducer set pacemaer implantation. 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 Figure 4.

Subclavian vein puncture is the first choice technique for most operators. The needle is advanced Hump tulip washington aspirating on an attached syringe as with any other indirect punctureaiming for the space below the clavicle and over the first rib until either the vein is cannulated or the rib is struck.

The subclavian vein is typically accessed at the junction of the first rib and the clavicle. On occasion, venography may be required to visualize the vein adequately or to confirm its patency Figure Pdrmanent.

This approach is pacemakeer with minimal incidence of pneumothorax. Contrast venography performed from left brachial vein. The figure clearly shows axillary vein, cephalic vein, subclavian vein.

Other important alternative central vein techniques for lead implantation are cephalic vein cut down and axillary vein puncture. The cephalic vein resides in the sulcus between the deltoid and pectoral muscles.

This area is easily identified by palpation and is occupied by loose connective tissue and fat, which can be dissected to identify the cephalic vein. Occasionally, the vein is deep or consists of a plexus of tiny veins. In these circumstances, other routes should be used for lead insertion. After vein isolation for 1 to 2 cm within the groove, it is ligated distally.

A ligator is placed around the proximal part of the vein for hemostasis. The vein can be entered using venotomy or with or guage peripheral IV catheter. The axillary vein can be accessed by blind percutaneous puncture by entering the pectoral muscle just medial to the acromion process on anteroposterior fluoroscopy. The needle then is directed to the point at which the lateral border of the first rib appears to cross the inferior margin of the clavicle.

Alternatively, the axillary vein can be accessed using contrast venography. 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 Define lubricant personal the venacaval 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 Model yana cova 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. Although the pocket may be formed in the axilla or in the abdomen for epicardial or femoral systemsthe most common site is the pectoral region. In the latter approach, a 1.

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. 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. 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 paecmaker performed at 10 V to make lnsertion 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 Permanwnt 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 Peermanent, impedance is assessed, the ppacemaker is withdrawn, and the lead is secured to the underlying pectoralis with a nonabsorbable suture.

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. 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 hours to limit movement. 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.

There is controversy over the routine use of IV or oral antibiotics after the procedure. A postoperative chest radiograph is usually obtained to confirm lead position and rule out pneumothorax. Before discharge on the following day, posteroanterior knsertion lateral chest radiographs will be ordered again to confirm lead positions and exclude delayed pneumothorax. Pacemaker interrogation pacmaker also recommended to ensure proper pacing function before patient leaving the hospital.

Licensee IntechOpen. Permnent chapter is distributed under the terms of the Creative Commons Attribution 3. Help us write another book on this subject and reach those readers.

Step by step hands on video guides for Cardiac Pacemaker Implantation as referenced in rennatatropeano.com website, a guide for physicians, nurses, technicians. A pacemaker is a small device that is placed in the chest or abdomen to help control abnormal heart rhythms. Find out more about who needs a pacemaker, how they work, what to expect during and after pacemaker surgery, the risks of pacemakers, their effect on lifestyle, and how to . A permanent pacemaker insertion is a minor surgery and can be done on an inpatient or outpatient basis. Doctors may perform the procedure in an electrophysiology laboratory, operating room, or outpatient surgical facility. The patient is given a local anesthetic, and the insertion site is cleaned and shaven.

Permanent pacemaker insertion. chapter and author info

Related Topics Cardiovascular Arrhythmia Treatment. When the heart beats at a rate faster than the programmed limit, the pacemaker generally monitors the heart rate and will not pace. This type of treatment is called cardiac resynchronization therapy or CRT. A chest X-ray will be done after the pacemaker implant to check your lungs as well as the position of the pacemaker and lead s. Our routine practice is to give 1 gram of cefazolin or vancomycin in penicillin-allergic patients one hour before the procedure. Implantation of pacemaker usually involves a combination of local anesthesia and conscious sedation. The results of the device check are reported to your doctor, who then determines the appropriate settings for the pacemaker. This allows the doctor and nurse to pace your heart rate if it is too slow, or deliver energy to your heart if the rate is too fast. Typically, the pacemaker is positioned superficial to the pectoralis, but occasionally, a subpectoral or inframammary position is required. Ask your doctor when you will be able to return to work. A pulse generator is a small metal case that contains electronic circuitry with a small computer and a battery that regulate the impulses sent to the heart.

A pacemaker insertion is the implantation of a small electronic device that is usually placed in the chest just below the collarbone to help regulate slow electrical problems with the heart. A pacemaker may be recommended to ensure that the heartbeat does not slow to a dangerously low rate.

A pacemaker or artificial pacemaker , so as not to be confused with the natural pacemaker of the heart is a medical device that generates electrical impulses delivered by electrodes to contract the heart muscles and regulate the electrical conduction system of the heart. The primary purpose of a pacemaker is to maintain an adequate heart rate , either because the heart's natural pacemaker is not fast enough, or because there is a block in the heart's electrical conductive system. Modern pacemakers are externally programmable and allow a cardiologist to select the optimum pacing modes for individual patients. Some combine a pacemaker and defibrillator in a single implantable device.