complications of pacemaker implantation. waleed roshdy

Complications Of Pacemaker

Implantation Waleed Roshdy

Assisstant Lecturer Tanta University

( Tanta Rhythm Group )

Acute complications of pacemaker implantation

Delayed complications of pacemaker therapy

Acute complications of pacemaker implantation

Complications Of Venous Access

PneumothoraxPneumothorax is often

asymptomatic and discovered on the routine post-procedure chest radiograph.

severe respiratory distress , pleuritic pain, and cough suggest the diagnosis.

If its extent is greater than 10% or a small pneumothorax does not resolve or enlarges on serial radiographs, evacuation is indicated.

HemothoraxCauses ???If a large sheath is mistakenly

inserted into the artery , it should probably be LEFT IN PLACE. until decision .

Air embolism Causes ???How to avoid ??

Complications of Lead placement

Arrythmia

So ???For patients at risk of asystole

during permanent pacemaker implantation, revision, or generator change, a Preoperative Temporary Pacing Wire should be considered.

Always Monitor The ECG especially during lead placement .

Perforation Internal or external Self sealing up to life threatening tamponade .Predisposing factors ??? How to suspect tamponade?

1. Poor sensing ,, capture thresholds2. Progressive hypotension3. Echocardiogram, fluoroscopy in LAO projection to

assess the cardiac silhouette4. Suspicion of perforation without tamponade may

be aroused by an extreme distal location of the lead tip at the cardiac apex , chest pain, an ECG pacing pattern of RBBB, Poor pacing and sensing thresholds may be seen. In such situations fluoroscopy or computed tomography scanning may be helpful in localizing the lead tip

Lead damage Insulation break >>> low impedence Lead fracture >>> high pacing

threshold Defect in the insulation between the

conductor wires of a bipolar lead >>>>oversensing and transient inhibition of pacemaker output. Detection of such intermittent dysfunction may require the performance of provocative maneuvers.

(In addition to symptoms in pacemaker dependant patients )

Acute complications of pacemaker implantation

Pocket hematoma How to avoid ??Hemostasis is inadequate, when

there is a co-existent coagulopathy, or when anticoagulant or thrombolytic therapy is begun soon after implantation.

When to evacuate ?? Hematoma progression,

excessive pain, and stress on the suture line.

Delayed complications of pacemaker therapy

Delayed complications of pacemaker therapy

Lead displacement (macro-displacement) >>>

obvious on fluoroscopy or radiography

(micro-displacement ) >>> accompanied by no obvious change in position

Factors increasing incidence ???? ( physician and patient

dependant )Twiddler’s syndrome ???

How to decrease incidence ??1. Ensuring a stable position at

implant, 2. Leaving a proper amount of

intravascular lead slack so that tension is not exerted at the tip by respiration or arm motion

3. Adequately anchoring the suture sleeve to underlying tissue

4. Limiting abduction and elevation of the ipsilateral upper extremity for a short time after implantation.

generator related complications

Infection

How to decrease incidence of infection ??? 1. Strict sterilizaion of tools ,,

operating room ,, patient ,, doctor and nurses.

2. Antibiotic coverage ( mainly against staphylococcus )

3. Diabetes mellitus and postoperative hematoma appear to be predisposing factors.

How to manage ?? Antibiotic therapy alone is rarely sufficient

to eradicate these infections, and removal of the pacing system is usually indicated.

Two-step approach with temporary pacing (if the patient is pacer dependent) to bridge the time between explantation and new device implantation a few days later.

After device removal, the infected pocket may be partially closed and a drain inserted, or packed with wet-to dry dressings and left open to heal by secondary intention.

MigrationMigration of the pacemaker

under the breast or into the axilla may place tension on the leads or result in the assumption of a position that is uncomfortable or is predisposed to erosion.

Erosion Caused by pressure necrosis of overlying

tissue or infection. The risk factors ??1. paucity of subcutaneous tissue, 2. mass and configuration of the pacemaker,3. need for extra hardware (e.g. lead adaptor)

in the pocket, the pocket’s construction4. irritation caused by activity or physical

manipulation or by articles of clothing. If erosion occurs, the system is considered

contaminated and current practice is removal of the generator and leads

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