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Ann Thorac Surg 1997;64:880-881
© 1997 The Society of Thoracic Surgeons

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Update

Permanent Pacemaker Implantation in Premature Infants Less Than 21,000 Grams of Body Weight

As Originally Published in 1992:

Updated in 1997 by Mikio Ohmi, MD, Kazuhiro Yamaya, MD, Yoshimi Shoji, MD, and Koichi Tabayashi, MD

Department of Thoracic and Cardiovascular Surgery, Tohoku University School of Medicine, Sendai, Japan

Although numerous techniques for permanent pacemaker implantation in the pediatric population have been reported in many centers, few reports have been published on permanent pacemaker implantation for premature infants with congenital heart block. We reported a technique of permanent pacemaker implantation in 2 premature infants less than 2,000 g of body weight [1]. Since then we have employed the same technique in 1 additional patient and performed generator exchange for battery exhaustion in 1 patient 4 years 6 months after the primary pacemaker implantation. All 3 patients have been observed at our outpatient clinic and are doing well.

Generator placement for small infants is difficult because of discrepancies in size between the patients and the pacemaker hardware. Subcutaneous implantation is common for adults and larger children because of the simplicity of implanting and replacing the generator; however, the scanty subcutaneous fat, thin skin, and exposed position of the generator stretching the skin over the generator invite skin necrosis and infection in small infants. Retroperitoneal, intrapelvic, and intrapleural generator placements provide the possibility of generator migration and interference with major organs contained therein and result in technical problems when the generator requires exchange. Subrectal [2, 3] and preperitoneal placement [4] or preperitoneal placement with suspension by the anterior rectus fascia [5] might be acceptable for infants and children; however, the subrectal space in the rectal sheath is too small and the peritoneum is too thin and fragile to create a relatively large generator pocket for premature infants.

Our technique of intraperitoneal generator placement using a Gore-Tex surgical membrane (W. L. Gore & Associates, Inc, Flagstaff, AZ) pocket fixed to the abdominal wall in the peritoneal cavity provides maximal space to implant the generator and reliable fixation to prevent generator migration (Fig 1A). In our second patient, the generator could be exchanged easily without opening of the free peritoneal cavity because the generator was in the pocket and attached to the peritoneum. At that time a new generator pocket was created in the intermuscular space between the internal and external oblique muscles (Fig 1B).

View larger version (117K): [in this window] [in a new window]   Fig 1. . (A) Anteroposterior roentgenogram taken after primary pacemaker implantation at 1 month of life shows the large generator in the peritoneal cavity. The lead is looped in the pericardial cavity and the subcutaneous layer of the left side of the abdomen. (B) Anteroposterior roentgenogram taken after generator exchange at 4 years 6 months of life. The generator is placed into the layer between the internal and external oblique muscles. The lead has shortened in the pericardium with growth of the patient.

Footnotes

Address reprint requests to Dr Ohmi, Department of Thoracic and Cardiovascular Surgery, Tohoku University School of Medicine, 1-1 Seiryo-cho, Aoba-Ku, Sendai, 980-77, Japan.

References

1. Ohmi M, Tofukuji M, Sato K, et al. Permanent pacemaker implantation in premature infants less than 2,000 grams of body weight. Ann Thorac Surg 1992;54:1223–5.[Abstract]
2. DeLeon SY, Ilbawi MN, Idriss FS. Pacemaker implantation in infants and children: a simplified approach. Ann Thorac Surg 1980;30:599–601.[Abstract]
3. Ulicny KS Jr, Detterbeck FC, Starek PJK, Wilcox BR. Conjoined subrectus pocket for permanent pacemaker placement in the neonate. Ann Thorac Surg 1992;53:1130–1.[Abstract]
4. Young JN, Bacaner TJ, Powell CA. Preperitoneal suprahepatic pacemaker generator placement in the pediatric population. Ann Thorac Surg 1997;63:1486–8.[Abstract/Free Full Text]
5. Robertson JM, Laks H. A new technique for permanent pacemaker implantation in infants and children. Ann Thorac Surg 1987;44:209–11.[Abstract]

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