Complications of Much Needed Rhinitis

Page 2 of 8 Kotsakou et al.
Pacamaker and pneumothorax
permanent cardiac pacing devices: (I) single-chamber Table 1 Absolute and relative indications
PMs-VVI: one pacing lead is implanted in the right Absolute indications
ventricle or right atrium; (II) dual-chamber PMs-DDD: Sick sinus syndrome
two leads are implanted (in the right ventricle and in the
Symptomatic sinus bradycardia
right atrium); this is the most common type of implanted
Tachycardia-bradycardia syndrome
PM, (III) biventricular PMs-BiV, also called cardiac
Atrial fibrillation with sinus node dysfunction
resynchronization therapy (CRT): in addition to single- or
Complete atrioventricular block (third-degree block)
dual-chamber right heart pacing leads, a lead is advanced
to the coronary sinus for left ventricular epicardial pacing. Chronotropic incompetence
CRT-P includes pacing and CRT-D includes defibrillation. Prolonged QT syndrome
CRT is mainly implanted to patients with heart failure, Cardiac resynchronization therapy with biventricular pacing
improving symptoms and quality of life (3,4). Indications Relative indications
for implantation of permanent PMs divided into three Cardiomyopathy (hypertrophic or dilated)
classes, as defined by the ACC/AHA/HRS guidelines for Severe refractory neurocardiogenic syncope
device-based therapy of cardiac rhythm abnormalities (6-8).
Absolute and relative indications are shown in Table 1.
An ICD is recommended as primary therapy in a subcutaneous pocket is created, where the generator will
survivors of cardiac arrest due to ventricular fibrillation or be implanted. After successful vein access, a guide wire
hemodynamically unstable ventricular tachycardia. ICD is advanced and placed on the right atrium or the vena
indications are secondary prophylaxis against sudden cardiac caval area under fluoroscopy. A second guide wire can
death and primary prophylaxis (9).
be positioned, if necessary, via the same route either by a
second puncture or by a double-wire technique in which
Technique of implantation two guide wires are inserted through the first sheath.
A sheath and dilator are advanced, and when sheath
A PM consists of: (I) a pulse generator which contains all
is set in the right place the guide wire and the dilator
the computerized information to sense the intrinsic cardiac
are retracted. Then the lead is inserted into the sheath
electric potentials and to stimulate cardiac contraction, and
and advanced under fluoroscopy to the appropriate heart
a battery; (II) leads, which are wires with electrodes at their
chamber, where is attached to the endocardium either
tips. These leads connect the heart to the generator and
passively with tines or actively via screw-in leads. When
transfer all the data between them (2).
implanting a DDD, the ventricular lead is the first to be
Implantation of permanent PM is performed in a
placed. When leads are securely placed, then the sheath
cardiac catheterization laboratory under local or less
common general anesthesia and is considered to be a is removed. Specifics tests for sensing and pacing are held
minimally invasive procedure. Transvenous access to the and to avoid stimulation of the diaphragm, pacing is set at
heart chambers is the preferable technique, commonly 10 V. The lead is sewn with a nonabsorbable suture to the
via a percutaneous approach of the subclavian vein, the underlying tissue and afterwards, the generator is placed
cephalic vein (cut-down technique), or rarely the axillary to the pocket and connected to the lead. Last, the incision
vein, the internal jugular vein or the femoral vein (4). In is closed with absorbable sutures and an arm immobilizer
some cases both subclavian vein and cephalic vein are is applied for 12-24 hours. The cut-down technique of the
punctured. The most common transvenous route is the cephalic vein demands extensive skin and muscle dissection
left or right subclavian vein, entered at the junction of the to visualize the vein. Occasionally, PM can be implanted
middle and inner thirds, where the first rib and the clavicle surgically via a thoracotomy, and the generator is placed in
are joined. The vein is usually blindly punctured, unless the abdominal area. Antibiotic prophylaxis is compulsory
there are certain anatomical abnormalities, such as chest for device implantation, routinely cefazolin 1 g i.v. 1 hour
wall or clavicle deformation. In these cases an initial brief prior to the procedure, or alternatively 1 g vancomycin
intravenous contrast injection-venography is attempted i.v. in case of allergy to penicillin and/or cephalosporins.
in the peripheral arm vein. After the puncture, a small The day following the implantation, a chest radiograph in
incision 3.8-5.1 cm is made in the infraclavicular area and standing position anteroposterior and lateral is performed,
© Annals of Translational Medicine. All rights reserved. www.atmjournal.org Ann Transl Med 2015;3(3):42

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Pacamaker and pneumothorax

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