Pulse generators pocket complications

Permanent pacemakers have also been implanted using the inferior vena cava via a retroperitoneal approach (Fig. 4.63) (117). This is usually in the setting of complex congenital anomahes and subsequent corrective procedures. Venous access to the right atrium and ventricle is complicated by loss of continuity between the right atrium and the superior vena cava. Bipolar active fixation screw-in electrodes are used for both the atrium and ventricle. The pulse generator is usually implanted in a subcutaneous pocket formed on the anterior abdominal wall. 

Pacemaker pocket erosion continues to be a problem (Fig. 4.104). This is best avoided by creating a pacemaker pocket that has maximum optimal tissue thickness. Occasionally, in extremely asthenic individuals, subpectorahs major muscle pulse generator placement should be considered to afford optimal tissue thickness. Patients can also present with preerosion secondary to pressure necrosis of the overlying tissue. Such situations represent a quasiemergency if one is to avoid complete erosion and wound infection. The patient should be reoperated, the old pocket abandoned, and new pacemaker pocket created away from the involved site. Sutton and Bourgeois incidence of pacemaker pocket complications are shown in Table 4.25 (17). 

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