Ann Thorac Surg 2000;70:1426-1428
© 2000 The Society of Thoracic Surgeons
How to do it
Pacemaker leads: a simple atraumatic method for replacing pacemaker electrodes
Scott D. Steinberg, MDa,
David A. Mayer, MDa,
Makis J. Tsapogas, MDa,
Marc K. Wallack, MDa
a Department of Surgery, Huntington Hospital, Huntington, New York, USA
Address reprint requests to Dr Steinberg, 130 West 12th St, Apt 9 G, New York, NY 10011
e-mail: csdocs{at}pol.net
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Abstract
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Early dislodgment or malfunction of pacemaker leads can result in significant morbidity and therefore must be corrected promptly. We describe a method of changing pacemaker leads that is atraumatic, maintains central venous access, and eliminates the need for venipuncture. Our technique is simple, highly reproducible, and can be performed with standard operating room instruments.
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Introduction
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Complications associated with permanent pacemakers include those related to venous access (ie, pneumothorax, bleeding, thrombosis, and air embolism), and those related to the pacemaker and its components. In the Pacemaker Selection in the Elderly (PASE) study involving 407 patients, the most frequent complication of pacemaker implantation was lead dislodgment, followed by pneumothorax [1]. In a prospective evaluation of 1,088 consecutive patients undergoing endocardial pacemaker implantation procedures, electrode displacement was the most common reason for reoperation [2].
Early dislodgment or malfunction of pacemaker leads can result in significant morbidity and therefore must be corrected promptly. When inserting the standard tined pacemaker leads, occasionally a stable initial position with a good threshold cannot be found or early lead dislodgment or malfunction may occur. The operating surgeon often makes the decision to remove the tined lead and replace it with a screw-in lead. Although this may sometimes simply involve changing leads in a preexisting venous cutdown, usually a new central venous puncture with resultant morbidity is required.
We describe a method of changing pacemaker leads that is atraumatic, maintains central venous access, and eliminates the need for venipuncture. It is emphasized that our technique is applicable only during the acute phase of lead malfunction or dislodgment. Leads that have been in place for longer periods of time may have formed scar tissue, adhesions, or encapsulation, and should be extracted by other methods [3].
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Technique
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Under fluoroscopic guidance the faulty or dislodged pacemaker lead is withdrawn until its tip is within the right atrium (Fig 1 A). A small cut is made in the sheath surrounding the pacemaker lead proximal to the level of the skin incision (Fig 1B). With the use of a vein pick or fine-toothed forceps, the guidewire tip is inserted for several centimeters into the sheath (Fig 1C). The pacemaker lead and "piggy-backed" guidewire are now advanced until the lead tip is within the right ventricle or inferior vena cava (Fig 1D). As the pacemaker lead is advanced further, the guidewire is gently withdrawn until its tip is flipped out of the lead sheath (Fig 1E). When the guidewire is free from the sheath, the pacemaker lead is carefully removed and the guidewire remains in the intravascular position. With the guidewire in proper position, access to the central venous system has been maintained. The obturator and breakaway sheath are then passed over the guidewire (Fig 1F), and the new pacemaker leads may be placed in standard fashion.
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Fig 1. (A) The faulty or dislodged pacemaker lead is withdrawn into the right atrium. (B) A small cut is made in the pacemaker lead sheath proximal to the skin level. (C) The guidewire tip is inserted for several centimeters into the sheath. (D) The lead and "piggy-backed" guidewire are advanced into the right ventricle or inferior vena cava. (E) As the pacemaker lead is advanced, the guidewire is gently withdrawn until its tip is flipped out of the sheath. (F) The obturator and breakaway sheath are then passed over the guidewire and new leads may be placed in standard fashion.
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Comment
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The central venous puncture technique provides rapid and easy access to the right side of the heart for pacemaker lead implantation. Central venous puncture may occasionally have serious complications including pneumothorax, hemothorax, venous and arterial lacerations, arterial cannulation, air embolization, chylothorax, arteriovenous fistula, nerve injury, massive hemorrhage, and death [1, 2, 4]. Although the incidence of complications with central venous puncture is low, the cutdown method is essentially devoid of such risks [5]. Our philosophy regarding permanent pacemaker lead implantation is that the use of central venous puncture should be limited. For several years we have been interested in optimizing methods of pacemaker lead implantation. In a recent article, we described a modified double introducer technique for permanent pacemaker lead insertion that employs venous cutdown [6]. We advocate venous cutdown as a safe primary method for PPM lead insertion. Similarly, when changing malfunctioning or dislodged pacemaker leads, an atraumatic approach should be taken.
Our current method of changing pacemaker leads is useful in that the morbidity of additional central venous punctures is avoided. We have employed this method with 11 patients without complications. In all cases, the guidewire was easily withdrawn from the pacemaker lead sheath. The leads were all withdrawn under fluoroscopic guidance, and the guidewires all remained in place. Our technique is simple, highly reproducible, and can be performed with standard operating room instruments. This method may be employed whenever lead dislodgement occurs. If lead malfunction is the indication for lead change, this method should not be used after 30 days from implantation, or when resistance is encountered with lead extraction. When clinically indicated, we would advocate our method of changing pacemaker leads in order to facilitate this operation and minimize intraoperative complications.
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Acknowledgments
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The authors acknowledge the technical assistance of Mr Wes Hart, Guidant Corporation.
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References
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Link M.S., Estes N.A., III, Griffin J.J., et al. Complications of dual-chamber pacemaker implantation in the elderly. Pacemaker Selection in the Elderly (PASE) Investigators. J Interv Card Electrophysiol 1998;2:175-179.[Medline]
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Aggarwal R.K., Connelly D.T., Ray S.G., Ball J., Charles R.G. Early complications of permanent pacemaker implantation. Br Heart J 1995;73:571-575.[Abstract/Free Full Text]
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Byrd C.L., Schwartz S.J., Hedin N. Lead extraction. Cardiol Clin 1992;10:735-748.[Medline]
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Chauhan A., Grace A.A., Newell S.A., et al. Early complications after dual chamber versus single chamber pacemaker implantation. Pacing Clin Electrophysiol 1994;17:2012-2015.[Medline]
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Furman S. Subclavian puncture for pacemaker lead placement. Pacing Clin Electrophysiol 1986;9:467.[Medline]
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Kolker A.R., Mayer D., Zingale R., Tsapogas M. Central venous puncture versus cutdown for permanent pacemaker lead insertion. Minerva Cardioangiol 1996;44:39-44.[Medline]
Accepted for publication April 3, 2000.
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Abstract
Introduction
