Permanent pacemaker placing

Patients with decompensated cardiac failure requiring the use of IV inotropic therapy (such patients should first be weaned from IV therapy before initiating carvedilol) bronchial asthma (see Warninas) or related bronchospastic conditions second- or third-degree AV block sick sinus syndrome or severe bradycardia (unless a permanent pacemaker is in place) cardiogenic shock clinically manifest hepatic impairment hypersensitivity to the drug. 

Fig. 4.27 Percutaneous venous access of the right internal jugular vein. Weitlaner retractor placed demonstrating the figure-of-eight stitch. (From Belott PH, Reynolds DW. Permanent pacemaker implantation. In EUenbogen KA, Kay N, Wilkoff BL, eds. Clinical cardiac pacing. Philadelphia WB Saunders, 1995, with permission.)...

Fig. 4.38 With the ventricular electrode in place, the lead stylet is positioned in the lower right atrium for stabihty, the guidewire is retained. (From Belott PH. A practical approach to permanent pacemaker implantation. Armonk, NY Futura Publishing, 1995, with permission.)...

In all patients, we prefer positioning a temporary pacemaker through the left femoral vein, leaving the right one available for ICE or transfemoral workstation, if required. The temporary PM should be placed far from the permanent lead tip, reducing the risk of displacement during dilatation. 

Initially, almost all pacemaker and ICD procedures were approached exclusively from the epicardial point of view. But with the development of a transvenous approach, either by cutdown or percutaneous techniques, now almost aU pacemaker and ICD procedures are approached on a transvenous or nonthoracotomy basis. Today, the epicardial approach is reserved for certain unique circumstances. Electrodes can be placed on the epicardium by a variety of techniques. This involves a subxiphoid incision, and limited thoracotomy, or direct application of electrodes on an exposed heart. Recently, mediastinoscopy and thoracoscopy have been used to apply permanent pacing and rate-sensing electrodes as well as patch electrodes. The transvenous approach can be performed by venous cutdown, percutaneous venous access, or a combination of the two. 

In a similar approach, pacemaker leads have been placed via transhepatic cannulation (Fig. 4.64) (118). Venous access is achieved percutaneously with the guidewire passed transhepaticaUy, the sheath set is applied, allowing the subsequent introduction of a permanent pacing electrode. Once again, this procedure has been reserved for complex congenital anomahes that preclnde venous access via a superior vein. 

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. 

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