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SOME HELPFUL TIPS FOR PACEMAKER
IMPLANTATION
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.
BLIND PACING
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.
BIPOLAR PACING DURING REBURIAL
FAIRLY WIDE AREA DURING REBURIAL/BOX CHANGE
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.
LEFT SIDED ABLATION AND OCCLUSION OF CORONARY ARTERY
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.
ABLATION OF A DUAL AV NODE PATHWAY
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. |
