Permanent pacemaker implantation technique: part I

Although device therapy is increasingly a subspecialty in its own right, permanent pacemaker (PPM) implantation remains one of the core skills of cardiologists. Most trainees will require at least basic skills in PPM implantation and the aim of this article (in two parts) is to provide a guide to the steps involved, and some of the fundamentals of technique. No article on this subject can be totally comprehensive and cover all the subtle nuances of technique used by different operators. Furthermore, like any practical skill it is only possible to give a flavour of the methodology in writing, and nothing can replace the practical tuition of an experienced implanter in the pacing theatre during a number of PPM implants. That having been said, before outlining some of the practical aspects of PPM implantation, the first step is to identify whether a patient needs a PPM. This may be straightforward, but there can be some complex cases. For this information the reader is referred to the various guidelines widely available.1–3 When it comes to the actual implant the following provides a step-by-step account. For any patient undergoing PPM implantation, appropriate informed consent should first be obtained. This includes the indication for implantation (often to prevent syncope secondary to bradycardia) and the risks associated with the procedure (table 1), which may be tailored to one’s own practice/institutional figures; also it is increasingly important to document other important information given to the patient—for example, rules regarding driving.4 Placement of an intravenous cannula is routine for administration of prophylactic antibiotics, administration of intravenous analgesia/sedation, and potentially to perform venography (see section on central venous access techniques). For this latter reason it is the author’s practice to make this at least a 20 G cannula in the left antecubital fossa (assuming …