HOW TO DO IT
Permanent Pacemaker Implantation in Premature Infants Less Than 2,000 Grams of Body Weight Mikio Ohmi, MD, Motohisa Tofukuji, MD, Kaori Sato, MD, Takahiko Nakame, MD, Naoshi Sato, MD, Kiyoshi Haneda, MD, and Hitoshi Mohri, MD Department of Thoracic and Cardiovascular Surgery, Tohoku University School of Medicine, Sendai, Japan
Pacemaker implantation in premature infants presents technical problems because of the relatively larger size of the pulse generator compared with their bodies. A new technique with which successful generator implantation was performed in 2 premature infants less than 2,000 g of body weight is described. The generator is wrapped in a Gore-Tex surgical membrane. A piece of membrane
overlying the electrical contact surface of the generator is removed, and the generator is fixed to the abdominal wall in the peritoneal cavity. The technique is simple to perform and would give relative ease in generator exchange.
R
reddish a few days later. Fluid accumulation was detected in the generator pocket. To prevent skin necrosis, we relocated the generator in a pocket of the peritoneal cavity when the patient was 14 days old. The other patient received two temporary epicardial leads on the right ventricle through a median sternotomy in the delivery room followed by elective pacemaker implantation in the peritoneal cavity at 20 days of life.
ecent advancement in pacemaker technology has expanded the indications for pediatric cardiac pacing. Small pulse generators have been available for clinical use, and many surgical techniques for generator placement have been introduced [l-71. However, the placement of a relatively large generator compared with the size of a premature infant is associated with many technical problems and remains a source of many complications. In this article, a new technique of pacemaker implantation in a peritoneal cavity that is simple to perform and easily applied to premature infants weighing less than 2,000 g is described.
Patients Two female patients with congenital atrioventricular block diagnosed by fetal echocardiography were delivered by cesarean section. Both patients showed positive circulating maternal syndrome Sjogren A antibody, and 1 patient's condition was complicated with hydrops fetalis. Their birth weights were 1,680 and 1,840 g with estimated gestational ages of 33 and 29 weeks and heart rates at birth of 55 and 48 beatdmin, respectively. They were placed on bradycardia treatment with emergency temporary pacing in the delivery room. One patient received a transvenous pacing lead from the femoral vein by means of cutdown, and the lead was advanced to the right ventricle under fluoroscopic control. After 5 days of temporary pacing, pacing failure occurred because of right ventricular perforation by the pacing lead tip. Emergency permanent pacemaker implantation was performed using a myocardial lead through a left anterolateral thoracotomy, and a pulse generator was implanted in the subcutaneous layer of the left abdomen. The skin over the generator was markedly protruded and turned Accepted for publication July 13, 1992. Address reprint requests to Dr Ohmi, Department of Thoracic and Cardiovascular Surgery, Tohoku University School of Medicine, 1-1 Seiryo-cho, Aoba-Ku, Sendai, 980, Japan.
0 1992 by
The Society of Thoracic Surgeons
(Ann Thorac Surg 1992;54:1223-5)
Technique A small left anterolateral thoracotomy through fourth or fifth intercostal space is performed and the pericardium is opened. The myocardial lead (model 325-452; TPL-Cordis, Inc, Englewood, CO) is attached to the epicardium of the left ventricle. After laparotomy is made using a midline abdominal incision, the lead is introduced from the left pleural cavity to the subcutaneous layer of the left upper abdomen, where the lead is looped. The lead then is passed through the abdominal muscle layer and peritoneum into the peritoneal cavity and connected to the generator (Nova 11, model 281-05s; Intermedics, Inc, Freeport, TX). The generator is wrapped in a sheet of GoreTex surgical membrane (W.L. Gore & Associates, Inc, Flagstaff, AZ). This membrane pocket is secured around the generator using silk sutures placed in the periphery of the folded membrane. A round piece of membrane overlying the electrical contact surface of the generator is removed (Fig 1).Several sutures that have been placed in the folded membrane are sutured to the abdominal wall in the peritoneal cavity with the electrical contact surface of the generator turned anteriorly toward the peritoneum (Fig 2). With the pacemaker implanted and functional, the midline incision is closed. The anteroposterior roentgenogram taken 1 month after the implantation is demonstrated in Figure 3. The postoperative course of the 2 patients was uneventful. The generator did not migrate and its position could be confirmed by palpation through the abdominal wall.
0003-4975/92/$5.00
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HOW TO DO IT OHM1 ET AL PACEMAKER IMPLANTATION IN PREMATURES
Ann Thorac Surg 1992;54: 1223-5
Fig 1. The pulse generator is wrapped in a sheet of Gore-Tex surgical membrane with suspension sutures. A round piece of membrane overlying the electrical contact surface of the generator is removed.
Comment Complete atrioventricular block is an uncommon congenital disease, occurring in about 1 of 20,000 newborns. Recent advances in fetal echocardiography facilitate early diagnosis of the presence and nature of diseases. Because one of the most common causes of the disease is maternal connective tissue diseases, which may progress against a rational therapeutic regimen, it is important to assess which fetus requires therapy. Hydrops fetalis, as in one of our patients, and fetal or neonatal death appear to be associated with ventricular rates less than 55 beats/min [8]; we therefore elected to deliver our patients prematurely and begin treatment with pacemaking. Although there have been several reports on pacemaker implantation in infants and young children, few have
Fig 2 . The pulse generator wrapped in a Gore-Tex membrane blanket is attached to the peritoneum with the electrical contact surface of the generator turned anteriorly toward to the peritoneum.
Fig 3 . Anteroposterior roentgenogram shows the large pacemaker generator in the peritoneal cavity. The lead is looped in the pericardial and pleural cavities and the subcutaneous layer of the left abdomen.
been published on premature infants. Various implantation sites have been employed to avoid the problems of patient discomfort, skin bulge, skin necrosis with infection, generator migration, and technical difficulties during generator exchange. Subcutaneous implantation is common for adult patients because of the simplicity of implanting and replacing the generator; however, the scanty subcutaneous fat, thin skin, and exposed position of the generator stretching the skin over the generator invite skin necrosis and infection in small infants. Retroperitoneal, intrapelvic, and intrapleural generator placements provide the possibility of generator migration and interference with major organs contained therein and result in technical problems when the generator requires exchange. Subrectal, intermuscular, and preperitoneal placement or preperitoneal placement with suspension by the anterior abdominal fascia might be acceptable for infants; however, the peritoneum, fascia, and muscle of premature infants are too thin and fragile to create a relatively large generator pocket. Our technique of intraperitoneal generator placement using a Gore-’I’exsurgical membrane pocket provides maximal space to implant the generator and reliable fixation to prevent generator migration. Furthermore, the generator can be exchanged without open-
Ann Thorac Surg 1992;X 1 Z S 5
ing into the free peritoneal cavity because the generator is in the pocket and attached to the peritoneum.
References 1. Idriss FS, Otto R, Nikaidoh H, Newfeld E, Paul MH. Implan-
tation of permanent pacemaker in the first month of life for congenital complete heart block. J Thorac Cardiovasc Surg 1973;65:851-5.
2. Salama FD. A suggested site for the implantation of myocardial pacemakers in infants and young children. Thorax 1976; 31:346-9. 3. Donahoo JS, Haller JA, Zonnebelt S, Neil C, Gott VL, Brawley
RK. Permanent cardiac pacemakers in children: technical considerations. Ann Thorac Surg 1976;22:584-7.
HOW TO DO IT OHM1 ET AL PACEMAKER IMPLANTATION IN PREMATURES
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4. Amato JJ, Payne DD, Rheinlander HF, Cleveland RJ. Inter-
muscular abdominal implantation of permanent pacemakers in infants and children. Ann Thorac Surg 1978;25:243-7. 5. Culliford AT, Isom OW, Doyle E. Pacemaker implantation in the extremely young. A safe and cosmetic approach. J Thorac Cardiovasc Surg 1978;75:763-4. 6. DeLeon SY, Ilbawi MN, Idriss FS. Pacemaker implantation in infants and children: a simplified approach. Ann Thorac Surg 1980;30:599-601. 7. Robertson JM, Laks H. A new technique for permanent
pacemaker implantation in infants and children. Ann Thorac Surg 1987;44:209-11. 8. Schmidt KG, Ulmer HE, Silverman NH, Kleinman CS, Copel JA. Perinatal outcome of fetal complete atrioventricular block: a multicenter experience. J Am Coll Cardiol 1991;91:136M.
Permanent Pacemaker Implantation in Premature Infants Less Than 2,000 Grams of Body Weight Mikio Ohmi, MD, Motohisa Tofukuji, MD, Kaori Sato, MD, Takahiko Nakame, MD, Naoshi Sato, MD, Kiyoshi Haneda, MD, and Hitoshi Mohri, MD Department of Thoracic and Cardiovascular Surgery, Tohoku University School of Medicine, Sendai, Japan
Pacemaker implantation in premature infants presents technical problems because of the relatively larger size of the pulse generator compared with their bodies. A new technique with which successful generator implantation was performed in 2 premature infants less than 2,000 g of body weight is described. The generator is wrapped in a Gore-Tex surgical membrane. A piece of membrane
overlying the electrical contact surface of the generator is removed, and the generator is fixed to the abdominal wall in the peritoneal cavity. The technique is simple to perform and would give relative ease in generator exchange.
R
reddish a few days later. Fluid accumulation was detected in the generator pocket. To prevent skin necrosis, we relocated the generator in a pocket of the peritoneal cavity when the patient was 14 days old. The other patient received two temporary epicardial leads on the right ventricle through a median sternotomy in the delivery room followed by elective pacemaker implantation in the peritoneal cavity at 20 days of life.
ecent advancement in pacemaker technology has expanded the indications for pediatric cardiac pacing. Small pulse generators have been available for clinical use, and many surgical techniques for generator placement have been introduced [l-71. However, the placement of a relatively large generator compared with the size of a premature infant is associated with many technical problems and remains a source of many complications. In this article, a new technique of pacemaker implantation in a peritoneal cavity that is simple to perform and easily applied to premature infants weighing less than 2,000 g is described.
Patients Two female patients with congenital atrioventricular block diagnosed by fetal echocardiography were delivered by cesarean section. Both patients showed positive circulating maternal syndrome Sjogren A antibody, and 1 patient's condition was complicated with hydrops fetalis. Their birth weights were 1,680 and 1,840 g with estimated gestational ages of 33 and 29 weeks and heart rates at birth of 55 and 48 beatdmin, respectively. They were placed on bradycardia treatment with emergency temporary pacing in the delivery room. One patient received a transvenous pacing lead from the femoral vein by means of cutdown, and the lead was advanced to the right ventricle under fluoroscopic control. After 5 days of temporary pacing, pacing failure occurred because of right ventricular perforation by the pacing lead tip. Emergency permanent pacemaker implantation was performed using a myocardial lead through a left anterolateral thoracotomy, and a pulse generator was implanted in the subcutaneous layer of the left abdomen. The skin over the generator was markedly protruded and turned Accepted for publication July 13, 1992. Address reprint requests to Dr Ohmi, Department of Thoracic and Cardiovascular Surgery, Tohoku University School of Medicine, 1-1 Seiryo-cho, Aoba-Ku, Sendai, 980, Japan.
0 1992 by
The Society of Thoracic Surgeons
(Ann Thorac Surg 1992;54:1223-5)
Technique A small left anterolateral thoracotomy through fourth or fifth intercostal space is performed and the pericardium is opened. The myocardial lead (model 325-452; TPL-Cordis, Inc, Englewood, CO) is attached to the epicardium of the left ventricle. After laparotomy is made using a midline abdominal incision, the lead is introduced from the left pleural cavity to the subcutaneous layer of the left upper abdomen, where the lead is looped. The lead then is passed through the abdominal muscle layer and peritoneum into the peritoneal cavity and connected to the generator (Nova 11, model 281-05s; Intermedics, Inc, Freeport, TX). The generator is wrapped in a sheet of GoreTex surgical membrane (W.L. Gore & Associates, Inc, Flagstaff, AZ). This membrane pocket is secured around the generator using silk sutures placed in the periphery of the folded membrane. A round piece of membrane overlying the electrical contact surface of the generator is removed (Fig 1).Several sutures that have been placed in the folded membrane are sutured to the abdominal wall in the peritoneal cavity with the electrical contact surface of the generator turned anteriorly toward the peritoneum (Fig 2). With the pacemaker implanted and functional, the midline incision is closed. The anteroposterior roentgenogram taken 1 month after the implantation is demonstrated in Figure 3. The postoperative course of the 2 patients was uneventful. The generator did not migrate and its position could be confirmed by palpation through the abdominal wall.
0003-4975/92/$5.00
1224
HOW TO DO IT OHM1 ET AL PACEMAKER IMPLANTATION IN PREMATURES
Ann Thorac Surg 1992;54: 1223-5
Fig 1. The pulse generator is wrapped in a sheet of Gore-Tex surgical membrane with suspension sutures. A round piece of membrane overlying the electrical contact surface of the generator is removed.
Comment Complete atrioventricular block is an uncommon congenital disease, occurring in about 1 of 20,000 newborns. Recent advances in fetal echocardiography facilitate early diagnosis of the presence and nature of diseases. Because one of the most common causes of the disease is maternal connective tissue diseases, which may progress against a rational therapeutic regimen, it is important to assess which fetus requires therapy. Hydrops fetalis, as in one of our patients, and fetal or neonatal death appear to be associated with ventricular rates less than 55 beats/min [8]; we therefore elected to deliver our patients prematurely and begin treatment with pacemaking. Although there have been several reports on pacemaker implantation in infants and young children, few have
Fig 2 . The pulse generator wrapped in a Gore-Tex membrane blanket is attached to the peritoneum with the electrical contact surface of the generator turned anteriorly toward to the peritoneum.
Fig 3 . Anteroposterior roentgenogram shows the large pacemaker generator in the peritoneal cavity. The lead is looped in the pericardial and pleural cavities and the subcutaneous layer of the left abdomen.
been published on premature infants. Various implantation sites have been employed to avoid the problems of patient discomfort, skin bulge, skin necrosis with infection, generator migration, and technical difficulties during generator exchange. Subcutaneous implantation is common for adult patients because of the simplicity of implanting and replacing the generator; however, the scanty subcutaneous fat, thin skin, and exposed position of the generator stretching the skin over the generator invite skin necrosis and infection in small infants. Retroperitoneal, intrapelvic, and intrapleural generator placements provide the possibility of generator migration and interference with major organs contained therein and result in technical problems when the generator requires exchange. Subrectal, intermuscular, and preperitoneal placement or preperitoneal placement with suspension by the anterior abdominal fascia might be acceptable for infants; however, the peritoneum, fascia, and muscle of premature infants are too thin and fragile to create a relatively large generator pocket. Our technique of intraperitoneal generator placement using a Gore-’I’exsurgical membrane pocket provides maximal space to implant the generator and reliable fixation to prevent generator migration. Furthermore, the generator can be exchanged without open-
Ann Thorac Surg 1992;X 1 Z S 5
ing into the free peritoneal cavity because the generator is in the pocket and attached to the peritoneum.
References 1. Idriss FS, Otto R, Nikaidoh H, Newfeld E, Paul MH. Implan-
tation of permanent pacemaker in the first month of life for congenital complete heart block. J Thorac Cardiovasc Surg 1973;65:851-5.
2. Salama FD. A suggested site for the implantation of myocardial pacemakers in infants and young children. Thorax 1976; 31:346-9. 3. Donahoo JS, Haller JA, Zonnebelt S, Neil C, Gott VL, Brawley
RK. Permanent cardiac pacemakers in children: technical considerations. Ann Thorac Surg 1976;22:584-7.
HOW TO DO IT OHM1 ET AL PACEMAKER IMPLANTATION IN PREMATURES
1225
4. Amato JJ, Payne DD, Rheinlander HF, Cleveland RJ. Inter-
muscular abdominal implantation of permanent pacemakers in infants and children. Ann Thorac Surg 1978;25:243-7. 5. Culliford AT, Isom OW, Doyle E. Pacemaker implantation in the extremely young. A safe and cosmetic approach. J Thorac Cardiovasc Surg 1978;75:763-4. 6. DeLeon SY, Ilbawi MN, Idriss FS. Pacemaker implantation in infants and children: a simplified approach. Ann Thorac Surg 1980;30:599-601. 7. Robertson JM, Laks H. A new technique for permanent
pacemaker implantation in infants and children. Ann Thorac Surg 1987;44:209-11. 8. Schmidt KG, Ulmer HE, Silverman NH, Kleinman CS, Copel JA. Perinatal outcome of fetal complete atrioventricular block: a multicenter experience. J Am Coll Cardiol 1991;91:136M.
