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Pacemaker Tips And Cases



IF subclavian access is difficult then:

  • Lower the head end of the patient. It will fill the vein.
  • Ask someone to pull the hand of the patient towards the feet, it will open the angle between first    rib and clavicle.
  • Using image intensifier push needle towards the middle of the sterno-clavicular joint.
  • In very difficult case inject contrast in the lateral vein in cubital fossa and record venogram.

If patient has a moderate to severe chronic obstructive airways disease then opt for a cephalic approach as even a minor pneumothorax will create severe problems.

If cephalic is difficult to find ask your colleague to pass a guide wire in the medial vein in cubital fossa. Guide wire can be felt in cephalic vein. If it is difficult at shoulder abduct arm. Be careful with sterile field.

Implant the pace-maker above the deep fascia. Avoid implanting it in sub-cutaneous tissue as it is likely to erode if implanted in subcutaneous tissue.

If implanting ventricular lead is difficult then make a loop across the tricuspid valve and advance the stellete.

If ventricular lead is aiming towards the RV outflow then advance a straight tip stellete just beyond the tricuspid valve(identified by the moving angle it creates in the lead)) and slowly pull the lead and tip should point downwards.

To improve the threshold of the lead keep a stellete in the lead but its tip should be well before the tip, now gently rock the lead over the stellete and tip is likely to catch a trabeculae.

If the patient has complete heart block with slow ventricular rate, he is likely to become dependent on the pacemaker when you are testing the threshold so first check the “R” wave amplitude to have an idea about the position.

Instilling an antibiotic powder as tribiotc or antiseptic as betadine in pacemaker pocket may reduce the chances of an infection.

In patients presenting with complete heart block carefully listen for a aortic stenosis murmur.

On right side the angle with subclavian and superior vena cava can cause problem in advancing the lead. Insert the guide wire in the sheath and then advance the lead, slight pull of guide wire while pushing the lead will be very useful.

Pacemaker can easily be implanted via a short incision as it will be easy to stitch. First make a adequate size pocket, then insert the pacemaker with inserting the round side then rotating the pacemaker.

When stitching the subcutaneous tissue aim to keep the knot below the fat. This can be achieved by starting the knot from deep fascia side.



If you have to implant a temporary wire without any image-intensifier then there are following choices:

  • Implant a transcutaneous system from the xhiphisternal angle. Push the needle in the heart and pull the needle. The literature with the system is self explanatory. This process is very traumatic.
  • Alternatively a temporary wire can be inserted via a left subclavian. It will tend to go in RV. Keep an idea about length to avoid going in IVC or knotting.
  • Use a flow guided lead.



In a Western European hospital one operator was reburying a pacemaker. It was not changed to bipolar pacing mode. He had left small area open in the sheath. When he took pacemaker out the patient went into asystole. Operator had inserted the pacemaker between the sheath and the skin. He could realize it and correct it but the patient had a prolonged asystole. The lesson from this incident:

  • Change the pacing mode to bipolar before starting the procedure
  • Leave a fairly wide area of skin open.
  • Consider using a iodine emitting sterile sheath.



In a western European hospital a patient required ablation of a left sided pathway. Ablation was attempted via femoral artery access. Immediately after ablation the patient developed chest pain and ST segment elevation. Urgent coronary angiography was done. It revealed total occlusion of circumflex artery. This complication was easily dealt by PTCA. Therefore in above situation use a view in which you are very happy with coronary anatomy.



In a Western European hospital a young girl underwent Ablation for above pathway.  The procedure was taking time and the oberator became extra enthusiastic. She developed intermittent symptomatic CHB and received a DDD pacemaker which got infected.  She had more physical and social symptoms from the treatment than the original disease.

Note: It is better to accept a failure than overtreat such a patient.

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