05 - Implantation Procedure WT

Implantation Procedure
Basic Requirements of a Professional FCR

● Speak clearly, loudly & firmly
● Be a good observer, listener & helper :
BE AWARE/ALERT; FOLLOW THE CASE
● Knowledgeable of the products and accessories
● Know clearly:
1. French size of the leads

2. French size of introducers needed
3. For Screw-in lead:
• No. of turns required for fully extending/retracting the screw
• How to verify whether the lead is fully extended or retracted under
fluoroscopy
4. Impedance range of the leads

5. Size and thickness of the device (show demo)
6. Features of the device
2SJM internal use ONLY

Just before the Implant
● Know about the patient background/ indication
● Discuss with the implanter to confirm everything:
○ IPG model used

○ Any change from the original plan? Tined or screw-in?
What approach he/she would like to use?
Cut down or puncture? Retain guide-wire? Split sheath?

Just before the Implant
● Final check for all the equipments: Programmer (including
software of the IPG for new models), sterilized PSA cable
(at least one more set for back-up)
● Interrogate the IPG to see any improper setting (right

polarity for the lead, rate response is off), input patient
data (as detail as possible: e.g. date of reposition).

● Prior to the case confirm
○ Type of case
• New case/ Change-out/ Upgrade
○ Make M/N, S/N and date of implant of all existing

hardware
• Call Company Representative for assistance if needed

● Know physician preferences

○ Single or double chambers, lead types and device
preference
○ Programming preferences
○ Be aware of physician implant preferences during case
Always BE AWARE/ALERT to the surrounding/

happening. FOLLOW THE CASE!

● What does the lab provide?
○ Shelf items (e.g terumo guidewire) vs company
provided.
• PSA cables
• Leads
• Device

● Equipment
○ Programmer with wand and sterile sleeve
○ PSA
○ PSA Cables
○ Pacemaker
○ Leads and introducers
○ Accessories- adapters, wrenches, stylets
○ Always have back up for any sterile item
○ Patient Information data sheet
○ Extra programmer paper

● Patient Prep:
● Review patient chart
○ Patient history
• History of PAF? Prior CABG? Previous MI?
○ Meds
• May affect patient’s heart rate or capture thresholds
◦ Sotalol
Amiodarone
○ 12 Lead ECG
○ Depend on country practice and hospital policy:
Where pt lives- who will be responsible for following pt?

● Indications
○ Symptomatic bradycardia
○ Heart block
○ Syncope
○ HOCM
○ Neurally Mediated Syncope
○ Ablate and Pace
● Refer to the AHA/ACC Guidelines

● Contraindications
○ Elevated INR- circulating nurse is responsible for
assessing any lab work prior to implant
● INR < 1.5-2 for operation

● (INR keep for 2-3 by Warfin for Atrial Fibrillation)
● INR= International Normalization Ratio

Pt Prep: •Fluoroscope (for OR)

•Heart Monitor/external defib/pacer
•Oxygen on patient – IV Access
•Grounding pad
•BP and O2 monitoring

● Implant site selection

○ Pt right or left handed
○ Sports
○ History of or planned mastectomy or radiation therapy
○ History of fractured clavicle- collar bone, dislocated
shoulder
○ Evidence of subclavian vein stenosis
○ In dwelling IV catheter (PICC line, central line)
○ Dialysis catheters

Device prep: (open programmers)
○ Interrogate device while in box
○ Check Battery voltage
○ Code leads
○ Enter patient information
○ Program implant brady parameters
○ Set up Stored EGM triggers
● You should know the preferences of the physicians in

your territory (depending on indication)

● PSA set up:
○ Set up the PSA parameters prior to implant in order to
quickly acquire thresholds
○ Some physicians request the PSA be left VVI at 40
bpm and on –for emergency ventricular pacing when
not measuring thresholds
○ May utilize only one PSA cable- and switch channels
on PSA

● Special Situations:
○ New Implant on pt with CHB and Temporary Pacemaker

• Can you describe what will happen when you begin threshold testing?
• If no intrinsic rhythm- what will you measure for sensing
• Any special precautions when placing leads?
○ Change out with no underlying rhythm

○ Do not disconnect 2 leads for A dependent patient, use
another PSA as temporary backup
○ Implanting a Dual chamber PPM in Pt who is currently in
AF
• Implications for atrial sensing and capture

Additional Rep prep:
● Ensure that scrub nurse has PSA cables and introducers

● Fill out any necessary paperwork
● Scratch paper ready for measurements
● Important!! Keep an eye/ear on Patients rhythm and vital
signs!!!

Implant Techniques

● Possible complications of the venous access site.
○ Pneumothorax
○ Hemothorax
○ Hemopneumothorax
○ Brachial plexus
○ Bleeding
○ Infection

● Preventive measures used to reduce complications.
○ Elevate feet/ place pt in Trendelenburg position
(Supine position with feet higher than head)
○ Use fluoro as guide
○ Venogram
○ Check clotting times
○ Make puncture more lateral!!

Venous Anatomy
Netter F, Atlas of Human Anatomy, Ciba-Geigy - Plate 201

● The 2 most common types of access techniques
○ Subclavian approach (puncture)
○ Cephalic cutdown
○ Axillary puncture or cutdown
Subclavian Cephalic

Venogram
Subclavian Stenosis prior to implant (post-central lines)
Subclavian vein Cephalic vein
Axillary
Basilic vein
vein
Markewitz & Hemmer, Manual of Pacemaker Therapy, p.40

● After Pt is sedated
● Site is injected with local anesthetic
● May use cautery to excise tissue
● Pocket may be made before or after venous access has
been obtained

● Establish line between coracoid
process and midpoint of sternal
angle
● Place needle at 2/3 out towards
cp, angle deep and towards
clavicle
● If hit first rib, pull back and
redirect posteriorly
● Magney, PACE 1993; 16: 2133

Seldinger Technique

Introducer Techniques
● 1. Single Stick Technique/ Retained Guidewire
○ Utilizes one stick for 2 leads
○ Must upsize 1 ½ to 2 french sizes for first lead
○ Second lead introduced will utilize the appropriate
french size
• Example: 2 x 7fr. Leads
◦ First lead uses 9fr. Introducer- guidewire is retained and
used to introduce second introducer then GW is removed
◦ Second lead uses 7 french introducer

● Introducer Techniques
● 2. Double Stick Technique

○ Utilized 2 individual venous access sites
○ May use recommended french size for each lead
○ Less likely to experience “tightness” in passing the
leads
• Ex: 2- 7 french leads
◦ use 2- 7fr. Introducers

● Cut down
○ Incision made
○ Tissue dissected to reach venous access site
○ Vein pick and silk suture (without needle) is used to
elevate and isolate vein
○ Small nick is made in vein and Guidewire is introduced

Cephalic Vein Access
 Cephalic vein  Cephalic

v.
Pocket Formation
Courtesy of Malcolm Clarke, M.D.

Rep Hints
● Be ready to hand off leads
○ Ventricular lead first
○ Atrial lead second

Lead Placement
● Ventricular Lead
○ Right Ventricular Apex (RVA)
○ Right Ventricular Outflow Tract (RVOT)
○ Right Ventricular Septum
• Ventricular Bradycardia Pacing
• Sensing Intrinsic Rhythm
• Watch out for patient’s in LBB
● Atrial Lead
○ Right Atrial Appendage
○ Atrial Septal Wall
• Atrial Pacing
• Atrial Sensing
● Always confirm lead position with fluoro

Lead Placement-Ventricular
● Passive Fixation
○ Advance into RA with straight stylet
○ Replace stylet with curved or Locator™ Plus stylet
○ Bank lead off of lateral atrial wall
○ Rotate and cross tricuspid valve
○ Advance to outflow tract or pulmonary artery
○ Replace curved stylet with straight stylet
○ Gradually withdraw lead allowing it to fall into apex

RV Lead-Positioned in Apex
Heel and
appropriate
slack

Lead Placement-Ventricular
● Active Fixation
○ Test screw before put into the body
Identical to passive fixation lead but final placement

not restricted to RV apex
○ Should not be placed in the coronary sinus or cardiac
vein
○ Acute capture threshold with helix extended may be
very high and progressively improve over 10-20 min.

Lead Implant Considerations
● In positioning ventricular lead, once lead crosses tricuspid
valve, pull-back stylet 1-2 cm to create “floppy tip” -
minimize chance of perforation;
○ Not an option with active fixation leads
● Pace at 10 Volts
○ If diaphragmatic stimulation - reposition
○ Assess by palpation over upper abdomen

Assessment of the Ventricular Lead Stability
● The stylet is withdrawn
● Monitor both Fluoroscope and ECG
● Patient is asked to take deep breaths and cough as hard
as possible
○ While pacing at 0.5 Volts > threshold
○ If intermittent loss of capture - reposition

RV Apical Location
● The apex is located medial to
lateral edge
● Apex may be compromised
by scar
● Other locations may be better
for hemodynamic reasons

Harmful??
Considerable evidence that
LV function may worsen
after RV pacing from apex

Alternate Sites for Ventricular Stimulation
● Right Ventricular Outflow Tract (RVOT) or septum
○ Requires active fixation lead
● Left Ventricle
○ Epicardial
○ Via coronary sinus - intentionally manipulate
lead into cardiac vein
● Coronary Vein (Biventricular)

What is the “alternative” to
traditional site pacing?
Right ventricular
outflow tract septum
Mimic normal contraction?

Right Ventricular Outflow Tract
Electrophysiologist’s
View
Septum Anterior
Posterior Free Wall (Antero-lateral)
(Postero-lateral) in front

PA LAO
PA LAO
RVOT Septal Pacing
How can we consistently place
our leads in the RVOT Septum?

Posterior angulation

Ventricular Lead-RV Apex
PA & Lateral Chest X-Ray

RVOT vs. Apex – X-ray Images
PA and Lateral
RVOT
RV Apex

RV Lead Placement

1788
Helix extended; markers resemble dumbbell

Markers together helix not extended

● Why are intraoperative measurements necessary?
○ To ensure the leads are electrically stable
○ Ensure good contact with healthy myocardial tissue

Pacing System Analyzers


Patient PSA Cable
When connecting the
alligator clips to the
terminal pin connector Red
(+) to ring, Black (-) to back
RED
Make sure the alligator clips

BLA
from the PSA cable are on the

to
terminal pin electrodes

CK t
Ring
and not the insulation

o Ba
ck

Patient Cable
Analyzer
Connection
Block
Biotronik style patient cable

connected to the analyzer cable to
the adapter
“Medtronic” style patient

connector works with
National Cable 4053A
adapter

Threshold Measurements
Sensing
Capture
10V
mA and Impedance
Sensing Determinations (Thresholds)
● May test VVI, AAI, DDD with long AV delays
● Utilize intracardiac electrograms on PSA if available
● Verbally denote measure P and R waves to physician
● Dismiss PVCs and the following R wave when measuring

in the ventricle
● If PSA does not measure signals, increase the sensitivity,

ensure the cable is hooked up.

Atrial and Ventricular Sensing Determinations
– Pacemaker
output stimulus is
inhibited while R-
wave is being
measured

● Acceptable ranges
○ P-waves >2.0mV
○ R-waves >5mV
• Not all patients will meet this criteria after numerous attempts
of positioning
● If P or R waves are marginal and no other position yields

better thresholds, measure Slew Rate

Slew Rate
V1
dV Slew Rate = dV/ dt

t2
dt Or change in voltage amplitude over time

Also knows as Slope
t1
V2-V1 dV
Slew Rate = = = Slope
V2 t2-t1 dt

Slew Rate of the Intrinsic Signal
● Acceptable R-Wave = 0.75 V per second
● or greater
● Acceptable P-Wave = 0.5 V per second

● or greater

Capture Threshold
V-Capture hints:
● Increase rate above patients rate
● Shorten AV / PV delays if in DDD mode
● May test in VVI, VOO, DDD or DOO
● Will also test at 10 V for diaphragmatic stimulation
(phrenic nerve)

Ventricular Capture Threshold Determination

Resistance (Impedance)
● Resistance in a pacing system is used to assure proper
continuity between the pacemaker and pacing lead
● NOT lead position!!

● Resistance (Impedance)
Normal Resistance = 200-2500 ohms
● Open Circuit > 2500 ohms

(Fractured conductor coil)
(Improper connection at header)
● Shorted Circuit <200 ohms

(insulation violation)

Current Injury (COI)
● When leads are in their final position
○ An electrogram should be recorded using either a PSA
(if allows EGM display) or ECG machine
● 2-3 mV COI is consistent with good endocardial contact
● Lack of a COI indicates poor endocardial contact
predisposing to
○ High chronic thresholds
○ Increased incidence of lead dislodgement

Current of Injury – Atrial Bipolar EGM – Passive Fixation Lead
Distal Unipolar Proximal Unipolar Bipolar 1 mV
The bipolar COI is an

Current of Injury involves the PR average of the tip and ring
segment – good endocardial unipolar COI
contact
Current Injury Pattern
Passive Ventricular Unipolar Electrogram

Capture Threshold and Impedance Measurements
● Bipolar
○ Be careful that alligator clips from PSA cable are on
terminal pins and not insulation
● Unipolar
○ Connect (+) alligator clip (anode) to a true indifferent
electrode or metal instrument placed in pocket.

Always check for:
○ Diaphragmatic stimulation by increasing the

voltage to 10 volts and maximum pulse width
available
○ If present – decrease to the maximum output
and Pulse width available on the PPM being
implanted
○ Have pt cough and deep breath during
evaluation

Causes Diaphragmatic Stimulation
● RV with very thin wall
● Coronary sinus - coronary vein placement
● RV perforation
● Atrial lead - close proximity to phrenic nerve
If Diaphragmatic Stimulation is present, lead should be

repositioned

Suture in the lead
● After all measurements have been obtained, lead is
sutured in place to the subcutaneous tissues
● Adequate slack must be left on the lead

Lead Fixation with Anchoring Sleeve
● Adequate intracardiac heel on A and V leads
● Secure non-absorbable suture to underlying fascia
● Then secure suture around anchoring sleeve
● Tighten sufficiently so that cannot advance or withdraw
lead using fingers

Anchoring Sleeves
Anchoring Sleeve with wings
Anchoring Sleeve without wings

Consequences of Improper Anchoring Sleeve
● Too loose
○ Lead pulls back and dislodges
○ Twiddler Syndrome
○ Lead pulls back and places tension at
electrode-tissue interface - high thresholds
● Too tight
○ Stress point on lead predisposing to conductor
fracture or insulation failure

Tight Ligature – Anchoring Sleeve

Tight Ligature - Pseudofracture

RA Lead Placement
Atrial lead movement in

the right atrial
appendage resembles
a hula dancer’s
movement? Wagging
tail movement
Lead Placement-Atrial
● Passive fixation - “J” lead
○ Advance with straight stylet
○ With tip of lead at juncture of RA/SVC, hold stylet
stable and advance lead into RA appendage
● Active fixation - straight lead
○ Advance with straight stylet into RA
○ Replace straight stylet with “J” stylet or steerable stylet
(LocatorTM)

Atrial “J” in right atrial Appendage

Lead Stability Assessment-Atrial
Monitor ECG and fluoroscopy while
● The atrial “J” stylet is withdrawn
● Patient asked to take deep breaths and cough as hard as
possible
○ while pacing at 0.5 Volts > threshold
○ intermittent loss of capture - reposition
● Pace at 150 ppm (ONLY atrium)
○ additional assessment of AV conduction
○ shake lead out of place

Atrial Lead Placement-Xray
● Right Atrial Appendage
○ Tip directed medial and anterior
● Malpositioned in RVOT
○ Tip directed medial and anterior
○ Tip to the left of midline
● Coronary Sinus
○ Low in atrium angled superior and medial
○ On lateral view - directed posteriorly
● Interatrial Septum (with active fixation)

Atrial Lead-Appendage
PA and Lateral Chest X-Ray

Atrial Lead-PA Chest X-Ray
RAA RVOT

A-Capture Hints
● Increase PSA rate 20-30 bpm above patient’s and look
for rate change
● Test in AAI if patient isn’t dependant and look for R-wave
conduction
● Lower pacing rate if patient exhibits an AV block
(Wenckebach) when pacing at higher rates
● Test in AOO if competing with intrinsic rhythm
● Utilize the EGMs on the PSA
● Utilize the fluoro to assess lead movement with pacing
and capture

Atrial Capture Threshold Measurement
R-waves Present R-waves Absent R-waves Present
Atrial Capture Regained

rial Capture Present
Loss of Atrial Capture

Atrial Capture Threshold Determination

Fluoroscopy-Capture
To determine atrial capture during AV
pacing (for patients in heart block)
1. Set the PSA pacing rate 30 ppm
above the patient’s sinus rate
2. Set the output voltage to a
subthreshold setting (0.1 V)
3. Turn fluoroscopy on and observe
movement of the lead tip (tip should
move at sinus rate)
4. Increase the voltage while observing
the lead tip under fluoroscopy
5. When the lead tip moves at a faster
rate, note the voltage setting
6. This is the capture threshold

● Acceptable Capture thresholds
○ Atrium- <1.5 V at 0.5 ms
○ Ventricle- <1.0 V at 0.5 ms
• Not all patients will meet this criteria after numerous positions

Handling the Sterile Package
● The device to be implanted should not be opened until
the pacing leads are in proper position
● Prior to opening the device, verbally confirm with the
operating physician that the device you are going to open
is the correct model for this patient

Lead/ Device Connection
● You should verify the atrial and ventricular lead serial
numbers of leads while physician is connecting the device
● Review the correct position in the header in the case of a
BIV or ICD device
● Monitor patient’s rhythm for pacing while the leads are
being connected to ensure proper connection.

Lead Connectors
IS-1 Connector in the Header

Tightening the Set Screw

Example of improper technique
Septum
Wrench
Silicon of
septum is
cored out
falling
into
setscrew
Example of improper technique
Recommended Wrench Insertion
○ Approach septum from a 45°angle
Recommended Wrench Insertion
1
3
4
How to ”find” the set screw
Silicone rubber sealing membrane

Cross section of ICD Septum (old vs. new design)
Septum
Setscre
w
Connection Issues
○ Leads reversed in header
• A-pacing captures the ventricle
• V-pacing captures the atrium
○ Loose set screw

• High impedance measurements

● Physician will close the pocket
● Verify appropriate pacing before physician leaves the

room!!!!
○ Surface ECG
○ Intracardiac electrograms

● Set up final programmed parameters and program device
once procedure is complete. May be done in the post-op
room.
● Final measured data

○ Capture and sensing tests
○ AutoCapture turned ON, per protocol
○ Lead impedances
● Print data and place in chart

Finalize paper work
● Implant information to physician and office
● Device booklet and ID card to patient’s family
● Patient registration to SJM
● Billing information to the hospital

● Post-op Care (physician specific)
○ Bed rest x24hr
○ Do not lift more than 10lbs with affected arm for 2-6 weeks
○ Do not raise affected arm above shoulder height
○ Keep clean and dry; Do not get incision wet
○ Check for signs of infection
• Redness or swelling
• Hot to touch
• Oozing
○ Follow up with physician in 7-10 days
○ Oral antibiotic therapy
○ Check for excessive or active bleeding

Before Replacement Implant
● Check the model & serial numbers of the old lead(s).
● Check the connector block of the old device.
● Check if adaptor or upsize sleeve is present.
● Bring the appropriate wrench to disconnect the old device
from the old lead(s).
● Bring the appropriate device to fit the old lead (s).
● We may need the measured data of the 1st implant &
follow-up for comparison.
○ Bring the PSA readings of the old implant record.
○ Bring the follow-up record.

IS-1 Bipolar Lead Connector
● All current leads manufactured have IS-1 connectors
○ 3.2mm diameter pin
○ Short pin
○ Sealing rings
Sealing
Rings
Terminal Proximal
Pin Ring

Lead Terminal Pin
M, 5 mm
S, 6 mm
K, 3.2 mm (IS-1)
T, 3.2 mm (IS-1)
C, 3.2 mm inline (VDD)

(for old version AddVent, obsolete now)
Bifurcated 3.2 mm (VDD)

BOX Change
114SJM
Just before the Replacement Procedure
● Interrogate the old IPG
○ Check whether the device is really ERI.
○ Turn off the Rate Responsive
○ Turn off AutoCap and program to bipolar, esp for
dependant patient.
○ Prepare indifferent electrode for unipolar old lead.
○ Decrease the lower rate to see whether the patient is
pacemaker dependent. Temporary pacemaker may be
necessary during the replacement procedure if the patient
is totally dependent, especially for unipolar system.
○ Some SSS patient has AV conduction but Vs cannot
escape without atrial activity (e.g. Ap is needed): Do not
disconnect both leads at the same time.

During the Replacement Procedure
● Pay Specially attention when :
○ When the IPG is going to leave the patient body (for
unipolar system).
○ When the implanter is disconnecting the IPG from the
lead.
● Remind if lost of capture is observed during the
procedure.

During the Replacement Procedure
● PSA Checking (Chronic)
○ Pacing threshold
• A.threshold < 2.5 V / V.threshold < 2.5 V
● If readings is unacceptable
○ Put in a new lead
○ Cap the old lead

After the Replacement Procedure
● Interrogate the IPG and see whether the lead impedance
is within the normal range.
● Do threshold and sensing test using the programmer and
compare the result with the implant data. If the old lead is
re-used, reduce the voltage and pulse width to provide 2
x safety margin, or turn on AutoCapture.

Pre-impant Preparation for Lead Reposition
Procedure
● Asking which lead is going to be re-position, and use
stylet of suitable length.
● Getting the patient record: we need the measured data of
the last implant for comparison.
● Bring extra sterilized stylets, screw-driver, fixing-tool (for
screw-in lead), silicon gel

Just before the Reposition Procedure
● Interrogate the IPG:
○ Turn off the Rate Responsive, Lead Monitoring if they
are on.
○ Turn off AutoCap and program to bipolar, esp for
dependant patient.
○ Decrease the lower rate to see whether the patient is
pacemaker dependent. Temporary pacemaker may be
necessary during the replacement procedure if the
patient is totally dependent, especially for unipolar
system.
○ Some SSS patient has AV conduction but Vs cannot
escape without atrial activity (e.g. Ap is needed): Do
not disconnect both leads at the same time.

● Potential Complications
○ Bleeding
○ Infection
○ Perforation requiring treatment
○ Pneumothorax or hemopneumothorax
○ Arrhythmias
○ Pain
○ Death

Lead-Perforation-Chest X-Ray
Furman, A Practice of Cardiac Courtesy - Dr. Mark Myers

Pacing, Futura, 1990 (3rd Ed)

Diagnosis of Lead Perforation
● Anatomical position atypical - wrap around apex
● Electrogram - monophasic upright without current of
injury pattern
● Chest X-Ray or Fluoroscopy
● 2-D Echocardiogram
● ECG - stimulation of LV (RBBB)

Management of Lead Perforation
● Baseline hemodynamics
● Withdraw lead under continuous EGM recording
● Monitor Vital Signs for 10-15 min.
○ If stable, reposition lead
○ If unstable, administer fluids and prepare for
pericardiocentesis
● Surgical back-up

Troubleshooting
Recorded
immediately
post-implant.
The atrial
sensing
threshold was
1.8 mV, the
ventricular
sensing
threshold was
12 mV
What is the cause of this behavior?

The tracing shown below was recorded with the pacemaker in
the DDD mode, 4 V output on both atrial and ventricular
channels, base rate 60 ppm and AV delay 165 ms. What is the
problem if any?

The device is hooked up and the following ECG is

seen. Is this normal? If not, what is occurring?

This ECG strip is handed to you post implant. What is

the most likely diagnosis?

atrial lead
in the ventricle

Management of Pocket Hematoma
● Observation and close follow-
up
○ Soft
○ Minimal to no tenderness
● Surgical evacuation
○ Tense pocket threatening
suture line
○ Weeping suture line
○ Severe pain
○ Immunocompromised host

Causes of Open Circuit Due to Implant Technique
● Loose set screw

● Improperly seated lead
terminal pin
● Conductor fracture
○ Rib Clavicle Crush
○ Tight ligature
● “Dry” pocket - air in
pocket with unipolar
configuration
○ Replacement

Pulse Generator Pocket Chronic
● Pain - pocket neuralgia
○ Incorrect tissue plan
○ Incorrect location - too lateral
○ Smoldering infection
● Erosion
○ Pressure necrosis
○ Smoldering infection
● Migration
● Twiddler’s Syndrome

Conductor Fractures
● Occurs at stress points

○ Rib-Clavicle Crush
○ Tight Anchoring sleeve
ligature
○ Angulation of lead
○ Traction on lead
● If external conductor of
bipolar lead, conversion
to unipolar will allow for
elective management

Conductor Coil Fracture

Insulation Damage

05 - Implantation Procedure WT

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Implantation Procedure

Basic Requirements of a Professional FCR

1. French size of the leads

4. Impedance range of the leads

2SJM internal use ONLY

● Know about the patient background/ indication

● Discuss with the implanter to confirm everything:

○ IPG model used

3SJM internal use ONLY

● Interrogate the IPG to see any improper setting (right

4SJM internal use ONLY

○ Make M/N, S/N and date of implant of all existing

5SJM internal use ONLY

● Know physician preferences

Always BE AWARE/ALERT to the surrounding/

6SJM internal use ONLY

7SJM internal use ONLY

8SJM internal use ONLY

9SJM internal use ONLY

● Refer to the AHA/ACC Guidelines

10SJM internal use ONLY

● INR < 1.5-2 for operation

● INR= International Normalization Ratio

11SJM internal use ONLY

Pt Prep: •Fluoroscope (for OR)

12SJM internal use ONLY

● Implant site selection

13SJM internal use ONLY

● You should know the preferences of the physicians in

14SJM internal use ONLY

15SJM internal use ONLY

○ New Implant on pt with CHB and Temporary Pacemaker

○ Change out with no underlying rhythm

16SJM internal use ONLY

● Ensure that scrub nurse has PSA cables and introducers

17SJM internal use ONLY

19SJM internal use ONLY

20SJM internal use ONLY

21SJM internal use ONLY

Netter F, Atlas of Human Anatomy, Ciba-Geigy - Plate 201

23SJM internal use ONLY

Subclavian vein Cephalic vein

Markewitz & Hemmer, Manual of Pacemaker Therapy, p.40

24SJM internal use ONLY

25SJM internal use ONLY

● Magney, PACE 1993; 16: 2133

26SJM internal use ONLY

27SJM internal use ONLY

28SJM internal use ONLY

● 2. Double Stick Technique

29SJM internal use ONLY

30SJM internal use ONLY

 Cephalic vein  Cephalic

Courtesy of Malcolm Clarke, M.D.

32SJM internal use ONLY

33SJM internal use ONLY

● Always confirm lead position with fluoro

35SJM internal use ONLY

36SJM internal use ONLY

37SJM internal use ONLY

Identical to passive fixation lead but final placement

38SJM internal use ONLY

39SJM internal use ONLY