Permanent Pacemaker Implantation Procedure
Permanent pacemaker implantation is a standardized surgical procedure typically performed under local anesthesia with conscious sedation in a cardiac catheterization laboratory or electrophysiology suite. 1
Pre-Procedure Preparation
- Complete evaluation of bradycardia and cardiac conduction delay to confirm indication
- Anticoagulation management (if applicable)
- Antibiotic prophylaxis administration prior to incision
- Local anesthesia with conscious sedation (general anesthesia rarely needed)
- Sterile preparation of the implantation site (typically left infraclavicular region)
Procedural Steps
1. Vascular Access
- Primary approach: Cephalic vein cutdown technique 1, 2
- Involves surgical isolation of the cephalic vein in the deltopectoral groove
- Modified guide wire techniques may be used to facilitate lead advancement 2
- Alternative approaches:
- Axillary vein puncture using fluoroscopic landmarks
- Subclavian vein puncture (higher risk of pneumothorax and lead crush)
2. Lead Placement
- Venous introducer sheaths inserted into the accessed vein
- Pacing leads advanced under fluoroscopic guidance to the heart
- Lead positioning:
- Right atrial lead: Positioned in the right atrial appendage or lateral atrial wall
- Right ventricular lead: Positioned at the right ventricular apex or septum
- For challenging anatomy, over-the-wire techniques may be used 3
- Electrical parameters tested:
- Sensing amplitude (P wave, R wave)
- Pacing threshold
- Lead impedance
3. Pulse Generator Placement
- Subcutaneous pocket created in the infraclavicular region
- Leads connected to the pulse generator
- Final electrical parameters verified
- Pulse generator placed in the pocket
- Pocket closed in layers with absorbable sutures
- Skin closure with subcuticular sutures or adhesive
Post-Procedure Care
- Chest radiograph to confirm lead position and rule out pneumothorax
- Arrhythmia monitoring for 12-24 hours 1
- Class I recommendation for pacemaker-dependent patients
- Class IIb recommendation for non-pacemaker-dependent patients
- Wound care instructions
- Activity restrictions (typically arm movement on implant side for 2-4 weeks)
- Device programming optimization
- Follow-up appointment scheduling
Potential Complications
Early complications (1-7% overall rate) 1:
- Lead dislodgement (1-2% for standard devices, up to 5.7% for CRT)
- Pneumothorax
- Hemothorax
- Cardiac perforation
- Pocket hematoma
- Infection
Late complications:
- Lead fracture
- Insulation breach
- Venous thrombosis
- Tricuspid regurgitation
- Battery depletion requiring generator replacement
Special Considerations
- Temporary pacing bridge: For pacemaker-dependent patients with device infection requiring extraction, temporary active fixation leads may be used until permanent reimplantation 4
- Device selection: Based on underlying rhythm disorder, patient characteristics, and anticipated pacing needs 1
- Programming considerations: Mode selection (AAI, VVI, DDD), rate response settings, and other parameters should be optimized based on the patient's condition 1
Permanent pacing remains the definitive treatment for symptomatic bradycardia, with expanding indications including cardiac resynchronization therapy for heart failure 5, 6.