Epicardial Permanent Pacemaker Implantation in a Neonate Through a Manubrium Sparing Sternotomy

This operative video demonstrates the technique for an epicardial pacemaker implantation in a newborn through a manubrium sparing sternotomy. The patient was a 6-day-old girl born to a mother who was a case of SLE. The antenatal fetal echo confirmed bradycardia, and the child was delivered at term with a birth weight of 2.6 kgs. Upon examination, the child had a heart rate of 42 beats per minute and no other obvious abnormalities. Preoperative ECG was suggestive of bradycardia with A-V dissociation. The surgical plan was to perform a manubrium sparing sternotomy, ligation of the PDA, epicardial lead implantation, and placement of the pulse generator (PG) through the same incision. The patient was prepped, draped, and manubrium sparing sternotomy performed. After the sternotomy, the pocket for pulse generator was created through the same incision after diving all attachments of the rectus muscle to the xiphoid. The plane was created just above the posterior rectus sheath. The authors try to preserve the posterior rectus sheath without entering the peritoneum.

The area needed for the PG was marked on the skin above so as to guide the authors regarding the size of the pocket. Use of a peanut is quite useful in dissecting this plane; at the same time, overenthusiastic devascularization is avoided to prevent the necrosis of the overlying skin. After creating the pocket for the PG, the pericardium was opened, and the PDA was dissected and clipped. The authors then proceeded to implant the epicardial leads. Initially, the leads were held in position temporarily to check for the site with the best threshold. After having confirmed the site for lead placement, they first sutured the ventricular leads. The first ventricular lead was fixed at the RVOT using a 5-0 proline suture. Additional bites may be taken to make sure there is proper contact between the lead and the epicardium. The second ventricular lead was positioned in the inferior surface of the heart. Do note that the ventricular lead on the inferior lead is positioned upside down. Care was taken that the leads were implanted in areas with no epicardial coronaries. Now they proceed to implant the atrial leads. The first atrial lead was implanted at the right atrial appendage. The second atrial lead was implanted near the IVC.

Two things to be noted while implanting the atrial leads: 1) they should be well away from each other and 2) they should be away from the phrenic nerve or else the diaphragm may get paced. After reconfirming, the thresholds the leads were connected to the pulse generator and the leads were coiled and placed in the mediastinum, making sure that there was no undue stress on the leads, hence avoiding lead fracture or dysfunction. The PG was placed in the pocket created. Once they made sure that the pacemaker is functioning well, they fixed the PG to the margins of the pocket. Chest closure was performed in a standard manner with a right pleural drain in situ. The child was doing well at the two year follow-up.

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