I admit it. For years, I got it all wrong. When I look back over the last 13 years since I left cardiology fellowship, I realize that my training to implant pacing devices was — at best — basic and foundationally flawed. Patient safety was almost an afterthought. Thankfully, with time (and after a few complications), my approach as an implanter has evolved. Along the way, I have stumbled across techniques that have allowed me to essentially start over and learn to do it right. Since leaving training, I have dramatically changed how I work, and I now have outcomes of which I can be proud. Without question, taking a careful approach that employs a handful of easily mastered steps (and which places safety first) can result in consistently successful implants with minimal complications and fluoroscopy use.
It’s easy to argue that anyone who adopts these (and similar) techniques can avoid many of the common mistakes, and feel confident about their work. I’ve categorized my recommendations here.
All patients coming to our lab have confirmed two working IVs. If the patient is pacemaker dependent, I will place a temporary pacing wire from the right internal jugular vein.
Cath Lab Environment
Having everyone’s full attention as well as the ability to communicate quickly and clearly with the staff is critical to the success of these procedures. Any operator knows that even the most straightforward procedure can quickly become complicated. Confusion between the operator and staff at these moments can raise the risk of complications. To this end, I never play music from the moment the patient arrives in the room to the moment they leave. In addition, all staff members wear headsets to allow for constant communication.
I don’t regularly perform a venogram. By using ultrasound guidance as outlined below, this is almost never indicated. If I am unable to pass a micropuncture wire easily into the superior vena cava because of stenosis or unusual anatomy, such as concern about persistent left superior vena cava, then a venogram will be obtained at that point.
One of the keys to safety during implant is using a consistent approach to procedure setup, with predictable step-by-step movements. For example, I place all sharp instruments in a kidney bowl. Next, I place towels in layers to separate tools depending on the steps involved. For instance, I have all access wires and sheaths on one layer. When I have access obtained, I cover this layer with a towel and build a second layer. On this towel, I place the ventricular lead and stylets. A third towel is then placed on top of the ventricular level, and on this I lay out the right atrial lead and stylets. This avoids confusion if I have to go back and reposition a lead or regain access. Also, I place any antibiotic flush solution into a clearly marked bowl, cover it, and move it out of reach so there is no chance I will inadvertently confuse this with saline flush.
Outside of infection, the greatest risk to the patient undergoing a device implant is pneumothorax or hemothorax. Successful vascular access starts with understanding that blindly passing any needle puts the patient at unnecessary risk. The use of handheld ultrasound guidance is critical. This allows direct visualization of access into the target vessel. I do not stick under the clavicle. Rather, I use a transcutaneous approach to access the left axillary vein using a micropuncture needle and wire with ultrasound guidance. If I cannot see and differentiate the left axillary vein from the artery and see their location in relationship to the lung, I will not puncture the skin with the needle. Rather, I will make a cut down and, using ultrasound inside the pocket, use this closer proximity to access the vessel.
Uncontrolled bleeding from vessel access can be a life-threatening issue. Once access is achieved and the cut down is performed, I place (but don’t tighten down) a single purse-string stitch using 0 silk around the access wire, which will allow me to achieve hemostasis at any time.
If ultrasound guidance is used along with the micropuncture access wire, a venogram is almost never indicated or necessary. Once access is achieved, I set the fluoroscopy setting on the lowest frame rate and use only “flashes” (i.e., momentary steps on the pedal), while transferring each image to a separate monitor. This allows me to confirm and document that the access wire is in the right atrium. Next, I upgrade to two delivery sheaths using a stepwise approach from the single micropuncture wire to two J wires. I then advance both leads into the right atrium, “flashing” intermittently on fluoroscopy to confirm their temporary position in the right atrium. Throughout the remainder of the case, I use only brief flashes of fluoroscopy to confirm that both leads are advancing into their final positions. Each flashed image is saved. My average fluoroscopy time per case since January 2014 for a dual-chamber device implant is under 60 seconds of fluoroscopy. Excluding the few complicated cases that have required more than 20 seconds, the average is under 15 seconds. Not infrequently, straightforward pacemaker and ICDs are implanted in under six seconds of fluoroscopy, without compromising safety.
Testing and Securing the Leads
I always place two sets of pacing cables and mark one of them with red tape on both ends, ready for backup pacing at all times. By marking both ends, there is no confusion between myself and my assistant as to which cable connects to which lead. Once I have removed the sheaths and accept the final position of the leads, I tighten the purse-string stitch, which almost invariably stops any back bleeding.
Closing the Pocket
I close with continuous running absorbable suture in three layers: deep, mid-level, and subcutaneous. I bury the stitch at the end and cover the wound with the Dermabond Prineo (Ethicon) skin closure system.
These situations pose a particular risk to safety, given the difficulty sometimes identifying and freeing existing leads. I exclusively use the PEAK PlasmaBlade (Medtronic) for these patients. Also, if temporary pacing is necessary, I will place a temporary pacing lead from the right internal jugular vein.
These and other techniques can be employed to reduce complications and fluoroscopy exposure. It is my hope that someday these techniques will be regularly taught to new fellows before leaving their training programs.
Disclosures: The author has no conflicts of interest to report regarding the content herein.