Asian Cardiovasc Thorac Ann 2003;11:11-13
© 2003 Asia Publishing EXchange Ltd
Single Midline Approach for Permanent Pacemaker Implantation in Children
Vichai Benjacholamas, MD,
Piroj Chotivittayatarakorn, MD1,
Porntep Lertsupchareon, MD1,
Sunthorn Muangmingsuk, MD1,
Apichai Khongphatthanayothin, MD1
Cardiothoracic Unit, Department of Surgery
1 Cardiology Unit, Department of Pediatrics, Faculty of Medicine, Chulalongkorn Hospital, Bangkok, Thailand
For reprint information contact: Vichai Benjacholamas, MD Tel: 66 2 256 4918 Fax: 66 2 256 5338 email: vichaicu{at}hotmail.com Cardiothoracic Unit, Department of Surgery, Faculty of Medicine, Chulalongkorn Hospital, 18th Floor, Sor Kor Building, Bangkok 10330, Thailand.
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ABSTRACT
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Permanent pacemaker implantation was carried out in 12 children with a mean age of 1.4 years (range, 2 days to 4 years) and a mean weight of 8.6 kg (range, 2.4–13.6 kg), using a single midline approach for placement of both the epicardial lead and the pacemaker generator (intermuscular abdominal implantation). Platinized porous-tipped steroid-eluting epicardial leads were used in all patients. The pacemakers worked well, and there was no early postoperative complication. This technique was found to be rapid, simple, and safe in children, especially neonates and infants.
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INTRODUCTION
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Permanent pacemaker implantation in neonates, infants, and young children (less than 10 kg) is associated with technical difficulties. Insertion of an endocardial lead is not possible because of the small size of the subclavian vein. Limited space for the generator is another major problem. Numerous techniques have been described for epicardial implantation in children, including placement through a thoracotomy, sternotomy, subxiphoid, or subcostal incision.1 The pulse generator has been placed in intraperitoneal, retroperitoneal, preperitoneal, intrapleural, or intermuscular sites.2–7 These approaches have employed single or two separate incisions for the lead and generator. To avoid a thoracotomy, a single midline approach was used to implant both the lead and generator in this series. The generator was implanted between the internal abdominal oblique and transversus abdominis muscles.
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PATIENTS AND METHODS
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Twelve pediatric patients underwent permanent pacemaker implantation in our institute between September 1995 and October 2000. Mean age was 1.4 years (range, 2 days to 4 years) and mean weight was 8.6 kg (range, 2.4– 13.6 kg). Three implantations were performed in the neonatal period, and 5 were carried out beyond infancy (Table 1
). The indications for permanent pacemaker implantation were congenital complete heart block or complete heart block after cardiac operation, viral infection, or myocarditis (Table 1).
With the patient in the supine position, the entire chest was elevated slightly by a pad beneath the back. A single vertical midline incision was made from the lower sternum just above the xiphisternal junction downward to the upper abdomen halfway between the xiphisternal junction and the umbilicus. A vertical incision was created at the left anterior rectus sheath close to the linea alba to expose the medial rim of the left rectus muscle. Lateral traction was applied to the rectus muscle to expose the left posterior rectus sheath. The rectus muscle was separated from the posterior rectus sheath by blunt and sharp dissection up to the lateral border of the rectus muscle. Dissection was continued between the internal abdominal oblique and transversus abdominis muscles until the pocket was large enough to accommodate the pacemaker generator (Figure 1). The xiphoid was split to expose the pericardium; in some patients, the lower end of the sternum had to be split to gain better exposure. A small self-retaining retractor was applied to expose the pericardium which was opened longitudinally, and stay sutures were placed. The anterior right ventricle was chosen as the site of the epicardial lead. Two 4/0 polypropylene sutures were used to tie the epicardial platinized porous-tipped steroid-eluting lead (Medtronic Capsure 4965; Medtronic Inc., Minneapolis, MN, USA). On obtaining a satisfactory pacing threshold, the lead was connected to the generator, with a loop inside the pericardium and the remainder coiled behind the generator. The generator was placed in the pocket. The pericardium was left open and the incision was closed in layers, without a drain. The positions of the lead and generator were demonstrated by postoperative chest radiography (Figure 2).
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RESULTS
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This technique was successful in all 12 patients. The electrical thresholds for each patient are shown in Table 1
. The mean operative time was 67 min (range, 50–90 min). There was no early postoperative complication. The lead was broken in one patient 3 years after implantation; reimplantation of a new epicardial lead was performed through a left thoracotomy incision. The lead had broken at the lower thoracic cage because the patient played football as a goalkeeper.
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DISCUSSION
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Similar to the subcostal approach, the subxiphoid single midline technique avoids a second incision and the discomfort of a chest tube which is necessary with the standard thoracotomy approach. A thoracotomy is also inadvisable for a patient with bilateral pneumonia. Furthermore, our approach avoids transgressing into the peritoneum. By this technique, the generator is concealed and very well protected within the fasciomuscular plane. This approach facilitates replacement of the generator through the previous incision, in contrast to intraperitoneal, retroperitoneal, or intrapleural placements that all require invasion of a major body cavity.
Although the subxiphoid approach only provides access to the right ventricle, placement of the lead at the thin-walled right ventricle was considered safe with a sutured epicardial lead. The limitation of this approach is the inability to place atrial leads. With the sutured epicardial lead, it is easy to remove the lead and resuture it to another area to obtain a better threshold for pacing. There was a high pacing threshold in a patient who had undergone a previous midline operation. All of the patients needed a pulse duration of more than 2 msec for capture. Therefore, it is suggested that the standard thoracotomy approach should be selected for a patient with complete heart block after a cardiac operation, to obtain the best area to place the lead. It was concluded from this series that placement of a platinized porous-tipped steroid-eluting epicardial lead via a single midline approach, together with intermuscular abdominal implantation of a permanent pacemaker, was rapid, simple, and safe in children, especially small neonates and infants with complete heart block and no previous cardiac operation.
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REFERENCES
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ABSTRACT
INTRODUCTION
