Eric M Wherley, MD1 and Irving David, MD2
1 Jackson Health System / University of Miami, Miami, FL, USA
2 Holy Cross Hospital, Fort Lauderdale, FL, USA
This chapter is a revision and update of that included in the previous edition of the TSRA Operative Dictations in
Cardiothoracic Surgery written by Jonathan C. Hong, MD and Jamil Bashir, MD
Essential Operative Steps
- Peripheral venous access and monitoring, preferably on ipsilateral side
- ECG monitoring
- Prophylactic antibiotics
- Creation of pacemaker pocket
- Seldinger subclavian vein access vs. cephalic vein cut down vs left anterior thoracotomy for epicardial lead placement
- Lead placement
- Pacing parameter testing (sensing, impedance, and pacing threshold)
- Lead connection to generator and placement of generator into pocket
- Wound closure
Potential Complications and Pitfalls
- The pocket is created before lead placement, thus reducing the chance of inadvertently displacing the leads once they are
positioned. Also allows for good hemostasis with electrocautery before device placement - The usual course of the cephalic vein is in the delto-pectoral groove, penetrating the clavi-pectoral fascia to join the
axillary vein medial to the pectoralis minor muscle. A variant of the cephalic vein runs over the superficial surface of the
clavicle to join the external jugular vein - The subclavian puncture site should be lateral to the costoclavicular junction to avoid the scissoring effect of the lead.
Ultrasound guided access of the subclavian vein may be performed by those trained in the technique - When encountering difficulty obtaining central venous access, a venogram can be performed using the peripheral
intravenous line in the antecubital fossa or through a venous access sheath. Increasing venous filling (Trendelenburg
position) may also help - In most patients, one can start with a 52cm lead. If this reaches the RV with sufficient excess length to loop behind the
generator, use this as your RV lead. The RA lead can then be 46cm. If the lead is too short to reach the RV, use it as your
RA lead and use a 59cm lead for the RV. - The RV lead can be inadvertently placed into the coronary sinus. Identification of coronary sinus placement includes: the
lead coursing more posterior than expected in the LAO projection, lack of ventricular ectopy, and a right bundle branch
block pattern when pacing on the lead - Preforming the RV lead stylet with a large C shape may aid in advancement to the RVOT, exchanging for a straight stylet
and slowly backing out allows for placement to the mid to distal septum. Purported advantages of distal septal placement
versus apical placement include narrower QRS, lower risk of perforation, and lower risk of diaphragmatic stimulation.
Active fixation is useful with septal placement - The RA lead in the right atrial appendage should course anteriorly in the LAO projection. The classical “figure-of-eight”
movement of the lead tip suggests the lead is in good position in the right atrial appendage. In patients with prior cardiac
surgery and absent appendage, the upper outer wall of the right atrium is an appropriate position. Check for phrenic nerve
stimulation in this case - If there are poor pacing parameters despite appropriate visual anatomic position, troubleshoot systemically by checking
all connections from the analyzer to the lead. If there are no correctable problems and the pacing parameters are still poor
after equilibration, then the lead will need to be repositioned - When checking the pacing parameters in bipolar leads, the black clip goes to the distal ring and the red to the proximal.
If using monopolar leads (rare, but may be seen in older generator changes), the black clip goes to the ring and the red
clip is attached to the subcutaneous tissue - Pacing parameter testing:
- a. Sensing (mV) should be P wave >1.5mV, R wave >5.0mV but preferably greater than 10mV. If the R wave sensing is too small, there is a risk of R-on-T arrhythmias and inappropriately sensing ventricular artifact as activity. For the RA lead, it is also important to consider the “far field” sensing of ventricular activity at the atrial lead. If the far field activity is high, then the atrial lead may inappropriately sense the ventricular activity as atrial
- b. Impedance (Ω) should be 400-1200Ω
- c. Pacing threshold (V) should be <2V at 0.4ms pulse width or <1.5V with a 1ms pulse width. The lower the value, the less energy is required to pace each beat. Maximal output pacing at 10V should also be performed to ensure there is no stimulation of the diaphragm or any extra cardiac structures, as well as no far field sensing
- If pacing parameters suddenly worsen, perforation may have occurred. Monitor for hemodynamic stability and consider
echocardiogram to rule out pericardial effusion - When securing the cephalic vein to the proximal end of the leads with a silk tie, ensure it is not too tight as to damage the
insulation of the lead - Ensure that the correct lead is placed in the correct port by checking serial numbers. Confirm that the lead is placed
completely into the generator and that all screws are tightened appropriately - All extra cable length from the leads is looped and placed posterior to the generator to prevent damage to leads when
performing subsequent generator changes - Epicardial leads should be positioned in an area free of epicardial fat and away from infarcted tissue for best pacing
characteristics - If epicardial leads are being placed and the infraclavicular pacer pocket is unable to be used due to concern for infection,
a pocket in the left upper quadrant may be created
Template Dictation
Preoperative Diagnosis: [INDICATION: e.g. sick sinus syndrome, etc.]
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Permanent [dual/single chamber] pacemaker insertion via [deltopectoral cutdown/Seldinger
access/left anterior thoracotomy]. [NOTE: If epicardial, two codes used: Epicardial pacing lead insertion via left
anterolateral thoracotomy AND insertion of pacemaker pulse generator].
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [SEX] with [COMPLAINT: e.g., syncope] and electrocardiographic evidence of [FINDINGS: e.g., sinus bradycardia < 40 beats/minute]. Leads Implanted: [Manufacturer/Model/Serial number] Device Implanted: [Manufacturer/Model/Serial number] Fluoroscopy Time: [Minutes] Pacing parameter characteristics: [Sensing (mV), Impendence (Ω), and Threshold (V) of each lead]
Description of the Procedure: The patient was seen and evaluated in the preoperative holding area and informed consent was
obtained. The patient was taken to the operating room/electrophysiology suite. The patient’s identity, consent, and planned
procedure were verified. The patient was placed on the operating table in the supine position. Prophylactic antibiotics,
analgesia, and sedation were administered to the patient as per hospital protocol.
Transvenous pacemaker insertion
We proceeded to prep and drape the chest and neck in the usual sterile fashion. A time out was performed confirming patient,
site, and procedure. [Amount] of [local anesthetic] was infiltrated along the planned incision and pocket. A 5cm incision
along the [infraclavicular/deltopectoral groove] was made. A combination of electrical cautery and blunt dissection was used
to create a pocket deep to the level of the prepectoral fascia.
Venous access [Seldinger technique]
A micropuncture needle was introduced from within the created pocket and advanced into the subclavian vein with aspiration
of venous blood. The micropuncture wire was advanced through the access needle and the needle was exchanged for a
micropuncture sheath. A 0.035inch guidewire was advanced under fluoroscopic guidance into the SVC and was utilized to
exchange the micropuncture sheath for a 7Fr peel-away sheath. The same technique was repeated 1cm laterally with a second
7Fr sheath placed. The RV lead was advanced through the first peel-away sheath.
OR [Cephalic Vein cutdown technique]
The deltopectoral groove was dissected to identify the cephalic vein and 2cm of the vein was freed from the surrounding tissue.
Distal and proximal control of the vein was obtained with 3-0 silk ties. The distal end of the vein was tied off. A venotomy
incision was made with Iris scissors. A vein lifter was used to insert the RV lead and a guide wire for the RA lead. After
placement of the RV lead, this guidewire was used to insert a 7Fr sheath.
Using fluoroscopy, the RV lead was advanced through the tricuspid valve and positioned in the [RVOT/high septum or RV
apex] using [active/passive] fixation. Anatomical positioning was confirmed in the LAO projection. Pacing parameters for the
RV lead were checked and documented above. A guidewire was inserted through the remaining sheath with passage to the
IVC. The introducer and guidewire were removed. The RA lead was inserted through the sheath and was positioned into the
right atrial appendage using fluoroscopy. Anatomical positioning was confirmed in the LAO projection. The sheath was peeled
away and removed. Pacing parameters for the RA lead were checked and documented as above. The pacing parameters for the
RV lead were rechecked. The RA and RV leads were secured to the generator and anchored into place with 2-0 nonabsorbable
braided tie around their suture sleeve. The leads were placed in loops posterior to the generator in the subcutaneous pocket.
The subcutaneous tissue was closed with two layers of running 3-0 vicryl. The skin was reapproximated with a running 4-0
monocryl subcuticular suture. The procedure was concluded, and the patient was transferred to the post anesthetic care unit in
stable condition.
Epicardial lead insertion
The patient was positioned in a partial right lateral decubitus position with the left side elevated using a gel roll and all bony
prominences were padded. The chest was prepped and draped in the usual sterile fashion. A timeout was performed confirming
the patient, side, site, and procedure. A #15 blade was utilized to make a 4cm incision along the 4th intercostal space between
the anterior and mid axillary line. Dissection was carried down through the muscle to the rib with electrocautery and through
the intercostal muscle over the top of the fifth rib. The pleura was entered, and the thoracotomy extended to the length of the
incision. A wound protector was placed, and a retractor was placed for exposure. Excess fat pad on the pericardium was excised.
A laparotomy pad was used for exposure. The pericardium was opened parallel and 2cm anterior to the phrenic nerve. 0 silk
pericardial sutures were placed to expose the lateral wall of the heart. A proposed site for placement of the left ventricular lead
was selected anterior to the obtuse marginal vein at the mid ventricular level. A kintner retractor was used to expose, at a site
free of epicardial fat and away from any infarcted tissue. A corkscrew pacing lead was brought into the field and secured at the
proposed site with 3 turns of the corkscrew, ensuring that the lead trails anteriorly from the electrode. The pacing lead was
tested with impedance, sensitivity, and pacing thresholds as documented above. The pericardium was reapproximated with 2-
0 silk suture. The retractor and wound protector were removed.
A 5cm incision transversely along the left upper chest was made 2cm below the midclavicular line. A combination of electrical
cautery and blunt dissection was used to create a pocket just deep to the prepectoral fascia.
The lead connector was brought through the thoracotomy and tunneled in a sub pectoral fashion to the pacemaker pocket,
where it was connected to the pacemaker and excess cable length coiled behind the device. A 28Fr chest tube was placed in
the left pleural space. The thoracotomy was then closed in layers. The fascia was reapproximated with 0 vicryl running sutures.
Scarpa’s fascia and the deep dermal layer were reapproximated with 3-0 vicryl suture. The skin was reapproximated with a
running subcuticular suture. The pacemaker pocket was closed in layers in a similar fashion. Dermabond and a sterile dressing
were applied. The procedure concluded and the patient emerged from anesthesia in a stable fashion.
Surgical counts were correct at the end of the procedure.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.
Multiple Choice Question(s)
During transvenous pacemaker insertion for a 68-year-old male with sick sinus syndrome, right atrial and right ventricular
leads with active fixation have been placed. The RA lead is placed in the right atrial appendage and RV lead in the apex. Initial
testing of the RV lead indicates a sensing R wave threshold of 2mV, capture threshold of 3V, and impedance of 1300 ohms.
The next step in management is.
A. Repositioning the RV lead to the interventricular septum
B. Connection to pacemaker generator and conclusion of procedure
C. Reevaluate pacing characteristics after a 5-minute waiting period
D. Removal of RV pacing lead and exchange for a passive fixation system
Answer: C. Active lead fixation systems tend to have significant improvement in sensed signals, capture thresholds, and lead
impedance over the first 20 minutes after insertion. Each redeployment of an active fixation helix increases risk of tissue injury
and myocardial perforation, particularly with elongation of the helix with multiple repositionings. Passive systems reach
equilibrium more rapidly. Septal versus apical pacing with the RV lead with regards to cardiac function is up for debate, septal
positioning does tend to be more challenging. Failing to address poor capture or sensing characteristics risks early device
failure. Exchange for passive fixation in itself would not necessarily improve pacing characteristics.
