waleed roshdy ,, TRG

1. Complications Of
Pacemaker Implantation
Waleed Roshdy
Assisstant Lecturer
Tanta University
( Tanta Rhythm Group )

2. Acute complications of pacemaker
implantation

3. Delayed complications of pacemaker
therapy

4. Acute complications of
pacemaker implantation

5. Complications Of Venous Access

6. Pneumothorax
 Pneumothorax 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.

7. Hemothorax
 Causes ???
 If a large sheath is mistakenly inserted
into the artery , it should probably be
LEFT IN PLACE. until decision .

8. Air embolism
 Causes ???
 How to avoid ??

9. Complications of Lead placement

10. Arrythmia

11. 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 .

12. Perforation
 Internal or external
 Self sealing up to life threatening tamponade .
 Predisposing factors ???
 How to suspect tamponade?
1. Poor sensing ,, capture thresholds
2. Progressive hypotension
3. Echocardiogram, fluoroscopy in LAO projection
to assess the cardiac silhouette
4. 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

15. 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 )

16. Acute complications of pacemaker
implantation

17. 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.

18. Delayed complications of
pacemaker therapy

19. Delayed complications of pacemaker
therapy

20. 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 ???

21. 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.

22. generator related complications

23. Infection

25. 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.

26. 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.

30. Migration
 Migration 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.

31. 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 construction
4. 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

33. THANK YOU