Transvenous pacing system implantation

Fig. 7.2 Serial anteroposterior fluoroscopic images taken during transvenous removal of a left-sided dual-chamber implantable cardioverter-defibrillator (ICD) system. After placement of a temporary right-ventricular (RV) pacing system

Implantation of transvenous ICD systems employs techniques similar to those used for permanent pacemaker implantations, and is discussed in detail in a separate chapter in this book. Connecting ICD leads to the device is slightly different than connecting pacemaker leads to pacemaker generators. All ICD pulse generators have at least three ports for single chamber devices (four ports for dual chamber devices, and five ports for CRT-D). One LV port is for the pace/sense IS-1 terminal pin, and two are for the defibrillation coil (usually DF+ and DF-). The second DF port may be capped if a single coil... 

A limited thoracotomy should be considered if both the superior (implant vein) and inferior (femoral) approaches fail to extract the lead. In 1985, Byrd and associates described a limited surgical approach for extracting chronic pacing leads that were unsuccessfully removed by transvenous techniques (46). A limited thoracotomy with low morbidity has been developed that totally avoids an extensive thoracotomy, as well as median sternotomy. This approach generally has been used as a primary approach in patients with uninfected lead systems that require removal. The transatrial approach allows for removal of leads that are inaccessible by the superior vena cava or inferior vena cava approach. This approach also affords ease of replacement of endocardial lead systems by the same technique. This is why it is most amenable to patients who are not infected. The transatrial approach with a limited thoracotomy has also been used for replacement of endocardial lead systems when all available veins have been obliterated after a superior vena caval or inferior vena caval extraction procedure. 

Mehta D, Nayak HM, Singson M, Chao S, Pe E, Camunas JL, and Gomes JA. Late complications in patients with pectoral defibrillator implants with transvenous defibrillator lead systems high incidence of insulation breakdown. Pacing Clin Electrophysiol. 1998 21 1893-1900. 

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