Implantation of Dual-Chamber Atrioventricular Pacemaker

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  • Sick sinus syndrome (SSS), especially if heart rate is <40 beats/min
  • Chronotropic incompetence
  • Second-degree type 2 atrioventricular (AV) block
  • Complete heart block (third-degree AV block)
  • Atrial fibrillation with pauses ≥5 seconds
  • Second-degree type 1 AV block (AV Wenckebach), if symptoms are present
  • Neuromuscular diseases, if conduction abnormalities are present
  • Infection at time of procedure
  • Risk of bleeding from elevated serum prothrombin time, partial thromboplastin time, or thrombocytopenia
  • During acute heart failure decompensation, hemodynamic instability, or acute myocardial infarction
  • Asymptomatic first-degree AV block
  • SSS or AV block that is expected to resolve (eg, Lyme disease, drug toxicity)
  • Should wait several days after cardiac surgery if bradycardia/AV block is present to see whether the electrical system normalizes.
  • If patient is pacemaker dependent, do not perform without temporary pacing wire to provide adequate ventricular rate during procedure.
  • Sterile mask, gown, gloves, and full sheet
  • Antibiotics
    • IV
    • Irrigation
  • Surgical instrument tray
  • Surgical drapes
  • Surgical topical antiseptic solution
  • Marking pen
  • Electrocautery machine
  • Pacing cables and pacing system analyzer for testing the lead(s)
  • Nonabsorbable suture
    • Anchoring sleeve on lead(s)
    • Pulse generator to muscle
  • Absorbable suture
    • Deep layer
    • Subcutaneous
  • Dressing
    • Nonadhesive dressing
    • Skin adhesive
    • Adhesive strips
  • Standard monitoring equipment: ECG, blood pressure cuff, pulse oximeter, external defibrillator patches, and external pacing capability
  • Resuscitation cart, including intubation equipment, resuscitation drugs, defibrillator, suction
  • Anesthesia equipment adequate to support conscious sedation
  • Local anesthetic
    • Lidocaine
    • Bupivacaine
  • Introducer sheath kit for each lead
  • Right ventricular lead
  • Right atrial lead
  • Pulse generator device programmer
  • Fluoroscope

Position of pulse generator

  • Usual placement is subcutaneously below the fat of the chest wall, superficial to the muscles, in a pocket created just below the clavicle on the side of the patient’s nondominant hand.

Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
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  • Links to medical evidence and related procedures

  • Monitor recovery from conscious sedation or anesthesia
    • Respiratory status
    • Blood pressure
    • Cardiac rhythm
  • Monitor for development of hematoma.
  • Monitor for adequate pain control.
  • Obtain chest x-ray to confirm lead position and rule out pneumothorax.
  • Many operators have the patient wear a sling on the ipsilateral arm overnight.
  • Complications of sedation
  • Pneumothorax or hemothorax during vascular access
  • Loss of capture from lead dislodgement
  • Lead perforation and cardiac tamponade
  • Lead dislodgement
  • Hemodynamic instability or respiratory depression from sedation
  • Bleeding or pocket hematoma
  • Device infection or cellulitis
  • Tricuspid valve damage
  • Ventricular tachycardia or fibrillation requiring external shock
  • Pocket pain
  • Acute heart failure decompensation
  • Death
  • Chest x-ray should show stable lead positions.

Ideally, the right atrial lead should have P waves >1.5 mV and threshold <1 V at 0.5 msec. The right ventricular lead should have R waves of >5-7 mV and threshold <1 V at 0.5 msec.

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