Lead placement permanent pacemaker

Fig. 4.29 Use of the right iliac vein for placement of pacemaker leads. The leads are nltimately tunneled using a Penrose drain to a pocket created in the right upper quadrant. (From EUestad MH, French J. Iliac vein approach to permanent pacemaker implantation. Pacing Clin Electrophysiol 1989 12(7Pt 1) 1030-1033, with permission.)...

Fig. 4.64 Lateral view demonstrating transhepatic lead placement. (Fishberger SB, Camunas J, Rodriguez-Femandez H, et al. Permanent pacemaker lead implantation via the transhepatic route. Pacing Chn Electrophysiol 1996 19(7) 1124-1125, with permission.)...

The indications for placement of a permanent pacemaker in a child are not substantially different than those that are published for adults. Children deserve special consideration, however, because of their smaller size, the different disease processes that lead to a need for pacing, and the effect of growth, development, and the simple passage of time on these disease processes. Becanse the risks of pacemaker implantation are affected by the size of the patient, it shonld not be surprising that patient size influences the indications for pacing. 

Shonld a complete obstrnction between the superior vena cava and right atrium be documented, it is likely that the only reasonable approach for pacing will be an epicardial system, although there is at least one report of the use of the transhepatic approach for placement of a permanent pacing lead in such a patient (43). However, if there is stenosis without complete obstruction, one may consider balloon dilation with or without placement of an expandable stent (44). If a stent is placed, one should not cross the site immediately with a pacemaker lead becanse of the chance of dislodging the stent. If a stent is not placed, one shonld still wait nntil the area has healed to avoid the possibility of disrnpting an area with a fresh intimal tear. 

Anatomic variations can alter the placement of the pacing system and therefore the radiographic appearance. It is not possible to discuss all potential anatomic variations. However, one anatomic variation does merit discussion - a persistent left superior vena cava. A permanent pacing system can be implanted via a persistent left superior vena cava (Fig.18.21). (If this anatomic variation is noted before pacemaker implantation, it is easier to implant the system via the right side if the patient has a normal right superior vena cava.) If pacing leads are implanted through a persistent left superior vena cava, the lead in the PA projection descends within the left side of the cardiac shadow and enters the atrium and then the ventricle by communication of the left superior vena cava and the coronary sinus. On the lateral projection, the ventricular lead is seen on the posterior cardiac wall within the coronary sinus. 

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