Ann Thorac Surg 1999;68:173-175
© 1999 The Society of Thoracic Surgeons
Original Articles
Placement of a permanent epicardial pacemaker in children using a subcostal approach
Kenneth G. Warner, MDa,b,
Dermot P. Halpin, MDa,b,
Charles I. Berul, MDa,b,
Douglas D. Payne, MDa,b
a Division of Cardiothoracic Surgery, New England Medical Center and Tufts University School of Medicine, Boston, Massachusetts, USA
b Division of Pediatric Cardiology, New England Medical Center and Tufts University School of Medicine, Boston, Massachusetts, USA
Address reprint requests to Dr Warner, Division of Cardiothoracic Surgery, New England Medical Center, 750 Washington St, Boston, MA 02111
e-mail: kenneth.warner{at}es.nemc.org
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Abstract
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Background. Previously described techniques for epicardial pacemakers in children have generally included either a left thoracotomy approach or a subxiphoid incision.
Methods. We have recently used a single left subcostal incision for placement of both the epicardial electrodes and the pacemaker generator. We report our initial experience with this technique in 8 patients. The mean age was 4 years (range, 4 months to 12 years). The smallest patient weighed 4,100 g.
Results. The subcostal approach was successful in 7 patients. One patient with a narrow costal margin operated on early in our experience required conversion to a thoracotomy. The pacing thresholds were uniformly excellent in all patients. There have been no associated complications.
Conclusions. Placement of epicardial leads using a left subcostal incision avoids a thoracotomy, is simpler than a subxiphoid approach, and results in acceptable thresholds with minimal morbidity.
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Introduction
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Advances in pacemaker technology in recent years have resulted in reliable and durable single and dual chambered systems that can be successfully inserted in many children using transvenous techniques [1, 2]. However there remains a subset of patients in the infant and pediatric population for whom transvenous insertion of electrodes is not possible. Included in this population are (1) patients with anomalies of the systemic venous pathways, either congenital or acquired; (2) patients with cavopulmonary connections and other types of Fontan circulation; (3) patients with abnormalities of the tricuspid valve including those with a tricuspid valve prosthesis; and (4) prohibitively small infants and children in whom placement of a transvenous system is unsafe because of the size mismatch between the electrodes and the subclavian vein. In most centers, children less than 10 kg are generally considered too small for safe placement of transvenous electrodes. For those patients, placement of an epicardial pacemaker system remains the best option.
Historically, ventricular epicardial electrodes often have been inserted through a left thoracotomy. Usually a small anterior incision is made, although a standard posterolateral approach can also be used [3, 4]. The generator is then placed using a second abdominal incision. In some centers a subxiphoid approach has been the preferred approach [4–6]. This technique has the advantage of avoiding a thoracotomy and requires only a single incision. Recently most of the surgical advances made in epicardial systems have focused on improved methods of creating the appropriate anatomic pocket for accomodating the pacemaker generator, particularly in small infants and neonates where tissue coverage of the relatively large generator can be difficult [7–12]. In these recently published reports, the electrodes were inserted using either the thoracotomy or subxiphoid approaches. Hence, there have been no recent changes in surgical placement of the surface electrodes.
In the 1970s Lawrie and colleagues [13, 14] reported their experience with a subcostal approach to placement of epicardial pacemakers in adults. For the past several years we have used this technique in infants and children with either congenital or acquired heart block. This report describes our initial results with this approach.
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Patients and methods
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Eight patients requiring epicardial pacemaker insertion at our institution were included in this study. The mean age was 4 years (range, 4 months to 12 years). The mean weight was 14.1 kg (range, 4.1 to 27 kg). Indications for pacemaker insertion included congenital complete heart block (n = 2), complete heart block after cardiac surgery (n = 2), sick sinus syndrome (n = 3), and complete heart block after balloon aortic valvuloplasty (n = 1).
The patient was placed supine with the left chest elevated slightly with a roll. A small incision was made parallel and one finger breadth below the left subcostal margin (Fig 1). The subcutaneous tissues were dissected and the anterior rectus sheath was divided [13]. The left rectus abdominis muscle was split in the directions of its fibers. The posterior rectus sheath was then traced superiorly up to the diaphragm. The attachments of the diaphragm to the ribs were dissected bluntly until the junction of the diaphragm and the fibrous pericardium was identified. The pericardium was then divided and stay sutures were placed. Exposure was facilitated by gentle downward traction on the posterior rectus sheath with a malleable retractor. Two screw-on electrodes were placed on the inferior surface of the left ventricle. Thresholds were then obtained. Using the same incision, a pocket was established beneath the rectus abdominis muscle medially and inferior to the internal abdominal oblique muscle laterally [7]. The pericardium was usually left open and the incision was closed in layers. Local anesthesia with 0.25% bupivicaine was used to infiltrate the dermis before closure.
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Fig 1. Operative approach for the placement of the epicardial electrodes and the pacemaker generator through a single subcostal incision.
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Results
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This technique was successful in 7 patients. One patient early in our experience had a particularly narrow costal margin. In this patient the exposure was suboptimal and therefore an anterior thoracotomy was done. There were no difficulties in placement of the electrodes in the remaining 7 patients. The electrical thresholds for each patient are shown in Table 1. The mean operating time was 88 minutes (range, 60 to 115 minutes). There were no postoperative complications. The mean length of stay was 3.3 days (range, 2 to 5 days).
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Comment
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The left subcostal approach has been used for placement of epicardial pacemaker leads for more than 30 years [13–16]. However, reports of its use have been restricted to the adult population, and until now it has not been reported in infants and children. In fact, Lawrie and colleagues [14] specifically stated that this technique is not recommended for younger age groups. Our initial experience with the subcostal approach suggests that this is an effective surgical approach applicable to a wide variety of patients, including infants. We also found this approach to be valuable in patients with previous cardiac operations because pericardial adhesions postoperatively are usually less dense along the diaphragmatic surface of the heart.
Similar to the subxiphoid approach, the subcostal technique avoids a second incision and the discomfort associated with a chest tube necessary with the standard thoracotomy approach. However, there are several additional advantages of the subcostal technique compared with the subxiphoid incision. The subxiphoid approach often requires excision of the xiphoid process and sometimes requires excessive retraction of the costal margin to obtain adequate exposure to the heart. In contrast, downward pressure on the posterior rectus sheath is usually the only traction required for acceptable exposure with the subcostal approach. The subxiphoid incision generally only provides access to the right ventricle. Conversely, the subcostal approach allows visualization of the inferior surface of both ventricles. This has a particular advantage when placing electrodes in small children whose thin-walled right ventricles could preclude safe placement of screw-on electrodes with the subxiphoid approach [13]. A recognized limitation of both the subcostal and subxiphoid approaches is the inability to place atrial electrodes.
The only patient in our series in whom a subcostal approach was not successful had a particularly narrow costal arch. With proper traction on the pericardial stay sutures and with gentle pressure on the posterior rectus sheath, we now believe that virtually all patients are appropriate candidates for the subcostal incision, including children with a narrow costal margin.
All patients in this series had insertion of screw-on electrodes. We have not used this approach with the steroid eluting electrodes, which generally require placement of sutures to secure the electrodes. Placement of sutures using the subcostal approach should be possible, although a longer pericardial incision and perhaps a slightly larger skin incision may be required. The wider availability of the steroid eluting electrodes has prompted us to expand the subcostal approach for their usage.
In summary, our initial experience with the left subcostal approach for epicardial pacing has been very gratifying. The exposure is generally excellent for proper placement of sutureless screw-in ventricular electrodes, as evidenced by acceptable electrical thresholds. Compared with the thoractomy and subxiphoid approaches, the subcostal technique is associated with minimal surgical trauma and can be considered a less invasive method. We recommend this technique for all patients, including infants and children who require a permanent single-chamber pacemaker.
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References
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Gillette P.C. Implantation technique for pediatric cardiac pacing. In: Gillette P.C., Zeigler V.L., eds. Pediatric cardiac pacing. Armonk, New York: Futura, 1995:37-61.
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Molina J.E., Dunnigan A.C., Crosson J.E. Implantation of transvenous pacemakers in infants and small children. Ann Thorac Surg 1995;59:689-694.[Abstract/Free Full Text]
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In: Kirklin J.W., Baratt-Boyes B.G., eds. Cardiac surgery: morphology, diagnostic criteria, natural history, techniques, results, and indications, 2nd ed. New York: Churchill Livingstone, 1993:1604-1605.
-
Rees P.G. Use of pacemakers in children. In: Stark J., de Leval M., eds. Surgery for congenital heart defects. Philadelphia, Pennsylvania: W.B. Saunders, 1994:139-148.
-
Stewart S. Placement of the sutureless epicardial pacemaker lead by the subxiphoid approach. Ann Thorac Surg 1974:308-313.
-
Salama F. A suggested site for the implantation of myocardial pacemakers in infants and young children. Thorax 1976;31:346-349.[Abstract/Free Full Text]
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Amato J.J., Payne D.D., Rheinlander H.R., Cleveland R.J. Intermuscular abdominal implantation of permanent pacemakers in infants and children. Ann Thorac Surg 1978;25:243-247.[Abstract]
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DeLeon S.Y., Ilbawi M.N., Idriss F.S. Pacemaker implantation in infants and children. Ann Thorac Surg 1980;30:599-601.[Abstract]
-
Robertson J.M., Laks H. A new technique for permanent pacemaker implantation in infants and children. Ann Thorac Surg 1987;44:209-211.[Abstract]
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Ulicny K.S., Detterbeck F.C., Starek P.J.K., Wilcox B.R. Conjoined subrectus pocket for permanent pacemaker placement in the neonate. Ann Thorac Surg 1992;53:1130-1131.[Abstract]
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Ohmi M., Tofukuji M., Sato K., et al. Permanent pacemaker implantation in premature infants less than 2000 grams of body weight. Ann Thorac Surg 1992;54:1223-1225.[Abstract]
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Young J.N., Bacaner T.J., Powell C.A. Preperitoneal suprahepatic pacemaker generator placement in the pediatric population. Ann Thorac Surg 1997;63:1486-1488.[Abstract/Free Full Text]
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Lawrie G.M., Morris G.C., Howell J.F., DeBakey M.E. Left subcostal insertion of the sutureless myocardial electrode. Ann Thorac Surg 1976;21:350-353.[Abstract]
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Lawrie G.M., Seale J.P., Morris G.C., Howell J.F., Whisennand H.H., DeBakey M.E. Results of epicardial pacing by the left subcostal approach. Ann Thorac Surg 1979;28:561-567.[Abstract]
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Parsonnet V., Gilbert L., Zucker I.R., Assefi I. Subcostal, transdiaphragmatic insertion of a cardiac pacemaker. J Thorac Cardiovasc Surg 1965;49:739-742.[Medline]
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Bhattacharya S.K., Sutaria M., Braunstein E.E. A method of epicardial pacing without thoracotomy. Chest 1972;62:112-114.[Abstract/Free Full Text]
Accepted for publication January 26, 1999.
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Abstract
Introduction
