Variations in surgical technique for permanent pacemaker implantation in West Midlands
Around 34,000 permanent pacemakers are implanted in England annually.1 With an increasingly ageing population, the rate of implantation is rising at an estimated rate of 4.7% per decade.2 However, there are no standardised guidelines on the surgical techniques for permanent pacemaker insertion. This has led to variability in practice among cardiologists across the country.
Permanent pacemaker insertion is associated with multiple complications, including pneumothorax, haematoma formation, lead displacement and infections. Overall, the rate of complications varies between 1% and 6% and depends on the approach adopted.3
We, therefore, investigated the current variation in pacemaker implantation practices in order to identify avenues for further research and improvement. We identified 13 National Health Service (NHS) hospitals with cardiology units involved in the insertion of permanent pacemakers in the adult population across the West Midlands. An email questionnaire, assessing variations in surgical technique of pacemaker implantation, was sent to the cardiology consultants across the region. Results were gathered from 30 out of 34 consultants in 11 of these hospitals. Paediatric cardiology units and private hospitals were excluded.
Preferred venous access
There is marked variability in preferred venous access among cardiologists. It was found that the majority (64%, n=19) prefer cephalic vein as the primary choice. Axillary and subclavian venous access accounted for 23% (n=7) and 13% (n=4), respectively. This is consistent with the previous study done in European centres.4 Likely reason for this is the minimal risk of pneumothorax associated with this technique.5
Type of suture for securing leads
Of the consultants, 86.7% (n=26) choose non-absorbable sutures for securing the leads, whether this is associated with less frequent lead displacement is not known. Further studies, based on this observation, may help in identifying the safest practice.
Suturing technique for pocket closure
Of respondents, 70% (n=22) use two layers of suture for subcutaneous tissue while 20% (n=6) prefer one layer. A further 10% (n=3) of the consultants have variable practice depending upon the thickness of the subcutaneous layer. Continuous sutures are preferred for subcutaneous tissue closure by 60% (n=18) of the operators while the remainder use intermittent sutures (n=12). However, there is no definitive evidence in favour of either technique.
Skin closure and pressure dressing
Two-thirds of the respondents (66.7%, n=20) prefer skin closure with sutures while 13.3% (n=4) utilise either glue or Steri-Strips instead. One-fifth of the consultants use a combination of glue and sutures.
The vast majority of cardiologists apply pressure dressing only if necessary (93.4%, n=28), due to concerns over skin integrity and device erosion, and just two practise its routine use.
Marked disparity was seen in the surgical techniques currently in practice for pacemaker insertion. This observational study provides an area for further research to investigate the complication rates related to different surgical techniques. This information can be of paramount importance for formulation of guidelines and standardising practice, in order to reduce the complication rates.
Conflicts of interest
Internal Medicine Trainee
Wye Valley NHS Trust, Hereford, HR1 2ER
1. National Institute of Cardiovascular Outcomes Research (NICOR). National audit of cardiac rhythm management devices and ablation: 2016/2017 summary report. London: Healthcare Quality Improvement Programme, 2019. Available from: https://www.nicor.org.uk/national-cardiac-audit-programme/cardiac-rhythm-management-arrhythmia-audit/
2. Cunningham D, Charles R, Cunningham M, de Lange A. Heart rhythm devices: UK National clinical audit 2009. London: Healthcare Quality Improvement Programme, 2010. Available from: https://bhrs.com/wp-content/uploads/2019/03/2009-CRM-National-Clinical-Audit-Report.pdf
3. Poole JE, Gleva MJ, Mela T et al. Complication rates associated with pacemaker or implantable cardioverter-defibrillator generator replacements and upgrade procedures: results from the REPLACE registry. Circulation 2010;122:1553–61. https://doi.org/10.1161/CIRCULATIONAHA.110.976076
4. Grazia Bongiorni M, Proclemer A, Dobreanu D et al. Preferred tools and techniques for implantation of cardiac electronic devices in Europe: results of the European Heart Rhythm Association survey. Europace 2013;15:1664–8. https://doi.org/10.1093/europace/eut345
5. Kirkfeldt RE, Johansen JB, Nohr EA et al. Pneumothorax in cardiac pacing: a population-based cohort study of 28 860 Danish patients. Europace 2012;14:1132–8. https://doi.org/10.1093/europace/eus054