Ann Thorac Surg 2007;83:1549-1552
© 2007 The Society of Thoracic Surgeons
Case Reports
Extrapleural Intrathoracic Implantation of Permanent Pacemaker in the Pediatric Age Group
Ravi Agarwal, MCha,
Ganapathy Subramaniam Krishnan, MCha,
Smartin Abraham, MCha,
Kinnari Bhatt, MDb,
Prem Sekar, MRCPc,
Snehal Kulkarni, MD, DNBc,
Kotturathu Mammen Cherian, FRACS, DSca,*
a Department of Pediatric Cardiac Surgery, International Center for Cardiothoracic and Vascular Diseases, Chennai, Tamilnadu, India
b Department of Cardiac Anesthesia, International Center for Cardiothoracic and Vascular Diseases, Chennai, Tamilnadu, India
c Department of Pediatric Cardiology, International Center for Cardiothoracic and Vascular Diseases, Chennai, Tamilnadu, India
Accepted for publication September 14, 2006.
* Address correspondence to Dr Cherian, International Center for Cardiothoracic and Vascular Diseases, R-30 C, Ambattur Industrial Estate Rd, Mogappair, Chennai 600 101, Tamilnadu, India (Email: drkmc{at}airtelbroadband.in).
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Abstract
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Permanent pacemaker implantation in pediatric patients poses challenges in finding a suitable pocket for generator implantation. We present our experience with 6 patients in whom the pacemaker was placed in an extrapleural intrathoracic location. We find that an extrapleural intrathoracic pocket is a useful site for generator placement in the neonatal and pediatric age group. It is safe, reproducible, and both the lead and generator can be placed through a single incision. We briefly discuss the advantages and disadvantages of other techniques that require a single incision for both lead and generator placement.
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Introduction
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Various sites and techniques have been reported in the literature for implantation of a permanent pacemaker in children. These include subcutaneous or submuscular pockets in the chest or abdominal wall [1, 2], the preperitoneal suprahepatic space [3], and also the peritoneal cavity, with the generator wrapped in polytetrafluoroethylene membrane [4]. We report a new technique of extrapleural intrathoracic implantation of the pulse generator. This pocket can be prepared either through a small, anterolateral thoracotomy or during sternotomy and has the advantage of placement of the epicardial electrode through the same incision.
Between September 2004 and December 2005, 6 children underwent extrapleural implantation of the pulse generator at our institution. They were aged were from 1 day to 7 years old and they weighed 1.8 kg to 14 kg. The diagnosis and indication for permanent pacemaker implantation and the follow-up duration are summarized in Table 1.
The patient is positioned in the supine position with a small roll placed under the left hemithorax. A small curved incision is made in the left submammary region in fifth intercostal space. The intercostal muscles are divided with electrocautery, and the parietal pleura is carefully reflected from the chest wall by blunt dissection using moist peanut swabs to create an extrapleural pocket just sufficient to accommodate the pulse generator. The pleura is reflected from the anterior and also from the left lateral surface of the pericardium, and the pericardium is opened between stay sutures.
A unipolar pacemaker lead is secured on to the anterior surface of the ventricle and the pericardium is closed using interrupted stitches. The lead is connected to the pulse generator, which is then placed in the extrapleural pocket. The generator is not anchored to the chest wall. A drain is usually not necessary, but if required, a small suction drain can be left in the extrapleural space and the thoracotomy is closed in a routine fashion. If the pleura is breached, it is sutured with interrupted fine Prolene (Ethicon, Somerville, NJ).
If a baby with congenital heart disease associated with complete heart block is undergoing intracardiac repair through a midline sternotomy, the extrapleural pocket is created by lifting the sternal edge and dissecting the parietal pleura from the thoracic cage. The pleura is reattached to the chest wall after placement of the pulse generator to prevent its migration.
This technique of extrapleural intrathoracic pacemaker implantation has been used successfully in neonates and infants who require permanent pacemaker implantation and also in a child in whom erosion of an infra-clavicular subcutaneous pacemaker pocket developed. The mean operating time was 23 minutes (range, 18 to 37 minutes), and there were no postoperative wound or lung complications. All the babies were extubated between 8 to 14 hours after the procedure. The mean follow-up period has been 12 months (range, 9 to 22 months).
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Comment
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Historically, the ventricular epicardial electrodes often have been inserted through a left thoracotomy, and a second abdominal incision is used to place the generator [5]. Other techniques, which have the advantage of the need for a single incision, are the (1) subxiphoid preperitoneal suprahepatic approach, the (2) subcostal approach anterior to the posterior rectus sheath, and (3) our technique of lateral thoracotomy approach with the generator placed in the intrathoracic extrapleural space.
The subxiphoid approach has the advantage of being rapid, and the same median sternotomy incision extended slightly inferiorly is used for creation of the generator pocket. The incidence of wound erosion, and disruption is reduced because of the full thickness of the abdominal wall covering the generator. The potential drawbacks of this method are the development of ileus, mediastinal or hepatic infections tracking into this space, ventral hernia development, intraperitoneal migration of the lead, or the generator or respiratory embarrassment from the upper midline abdominal incision. Adequate exposure of the heart for suturing the lead may occasionally be difficult. Creation of this pocket in patients with ascites or those with previous abdominal surgeries may be difficult [3].
The subcostal approach, in addition to having the advantage of using a single incision for both lead and generator placement, may be easier in those with previous cardiac operations because pericardial adhesions are usually less dense along the diaphragmatic surface of the heart and it provides access to the inferior surface of both ventricles. The disadvantages are that it may be unsuitable for those with narrow costal arches, exposure may occasionally be inadequate and it requires downward traction on the posterior rectus sheath, and the costal margin may interfere with the placement of the generator in small infants and children. The other potential disadvantages are lead fracture, pacemaker migration, and diaphragmatic stimulation [1].
The technique of extrapleural intrathoracic pacemaker implantation has the advantages of providing added protection from trauma because of the rib cage, does not interfere with diaphragm movement, good cosmesis, easy accessibility for generator replacement, a single incision for both lead and generator placement, and is less prone to lead fracture because the lead does not traverse any bony structure. The potential disadvantage could be extrapleural migration of the generator, which we have not seen in any of our patients.
We have not seen respiratory complications, even in very small infants, possibly because of the compliant chest wall and extrapleural location, which does not interfere with the lung mechanics. All these children could be weaned off ventilator without any difficulty. At the 20-month follow-up, the infant who required a pacemaker for congenital heart block showed normal lung growth, and the child had no respiratory symptoms (Figs 1, 2).
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Fig 1. Chest roentgenogram shows the generator placed in extrapleural location in the infant. The child did not have any respiratory complications, although the generator appears to occupy a significant proportion of the thoracic cavity.
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Fig 2. Follow-up roentgenogram in the same child shows normal lung growth at 20 months. (Patient 4 in the Table. Note the coil used for patent ductus arteriosus closure and also the unwinding of the epicardial lead with the growth of the patient.)
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This space can also be easily created by lifting one sternal table and by dissecting between the parietal pleura and the rib cage, using the sternotomy incision. This has the advantage of not requiring any additional incision for the creation of the generator pocket in those with preoperative heart block or those in whom the requirement for pacemaker has been decided preoperatively. When generator replacement is required in this group of patients, a small thoracotomy incision directly over the generator would help in explanting the generator. Though we have not explanted any generators in this series of patients, the senior author (K.M.C.), who has had experience with generator explantation, has found that the generator becomes "walled off" with a well-defined fibrous capsule and is easily enucleated.
There may be some reservation about using this technique with those with pleural adhesions, but we have seen that the pocket can be created easily under vision, as in the postoperative Fontan patient who developed infraclavicular generator pocket erosion. The presence of adhesions might confer the advantage of preventing generator migration.
In summary, the extrapleural intrathoracic location provides another useful site of generator placement that may be useful in small infants and neonates, patients in whom the need for pacemaker has been decided preoperatively, and those who have erosion of previously placed pectoral pacemaker generators. This space can be created by a thoracotomy or sternotomy approach. We have found this technique safe, rapid, and reproducible, with the advantage of requiring a single incision for both lead and generator placement.
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References
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- Warner KG, Halpin DP, Berul CI, Payne DD. Placement of permanent epicardial pacemaker in children using a subcostal approach Ann Thorac Surg 1999;68:173-175.[Abstract/Free Full Text]
- Molina JE, Dunnigan AC, Crosson JE. Implantation of transvenous pacemakers in infants and small children Ann Thorac Surg 1995;59:689-694.[Abstract/Free Full Text]
- Young JN, Bacaner TJ, Powell CA. Preperitoneal surahepatic pacemaker generator placement in the pediatric population Ann Thorac Surg 1997;63:1486-1488.[Abstract/Free Full Text]
- 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]
- Rees PG. Use of pacemaker in childrenIn: Stark J, de Leval M, editors. Surgery for congenital heart defects. Philadelphia, PA: W.B. Saunders; 1994. pp. 139-148.
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Abstract
Introduction
