Surgical Technique of Neonatal Epicardial Pacemaker Implantation

Conduction abnormalities of the heart are common in post-cardiac surgery patients and also in some congenital heart abnormalities. The epicardial PPI procedure was designed to address specific situations where traditional transvenous pacing was challenging or contraindicated such as complex congenital cardiac defects or limited venous access in childhood and the availability of hardware sizes (5). Unlike the conventional approach, which involved threading of leads through veins into the heart, epicardial pacing involves a more invasive approach of attaching the pacing leads directly to the epicardium via surgery. 

Technical Aspects 

The surgical technique used was divided into three steps. 

Step 1: Placement of Epicardial Leads 

Access to the Heart: 

Several approaches can be used, including: 

• Sternotomy—Standard midline (most commonly used) (6) or limited lower mini sternotomy (7) 
• Thoracotomy—Left anterior or anterolateral thoracotomy (8) 
• Subcostal—Subxiphoid incision in the upper rectus sheath (9) 
• Video-assisted thoracic surgery—A minimally invasive technique (10)

In the technique presented here, the authors described the placement of the epicardial pacemaker via the left anterior thoracotomy approach. 

After obtaining proper informed consent, the patient was taken to the operating room. The surgical procedure was performed under general anesthesia. The patient was positioned in a left lateral position with the left side elevated (300-450) and a small sand pillow placed below the rib cage to widen the left rib space, with the left arm toward the right side above the head. The patient was painted from above the chin to below the anterior superior iliac spine medially, the anterior midline of the body, and laterally up to the vertebral spine with povidone iodine. Draping was done to expose the anterolateral chest wall and left hypochondrial region. 

A skin incision was made along the upper border of the fifth rib, from 1 cm lateral to the midclavicular line to laterally up to the posterior axillary line. Using diathermy, the subcutaneous fat and intercostal muscles were split until the parietal pleura was reached. The pleural cavity was entered through the5th intercostal (IC) space. The left lung was protected with a warm wet gauze and retracted downward with a malleable retractor. The left ventricle was visualized medially. The pericardium was opened anterior to the phrenic nerve with diathermy. 

The site for epicardial lead placement was decided while mainly avoiding epicardial coronary vessels. Two epicardial pacing leads were fixed to the left ventricle’s (LV) antero-lateral wall avoiding epicardial fat and ensuring deep bites using 6-0 double-arm Prolene sutures with a 13 mm needle, keeping the black conducting surface of the leads in contact with the LV wall a minimum of 2 cm apart. The leads were connected to temporary pacing cables to check for impedance. The procedure may need additional sutures to increase the contact site or to change the site if high impedance occurred. 

Step 2: Tunneling of Leads to the Target Site and Pulse Generator Placement 

A 3-4 cm transverse skin incision was made in the proposed device placement site, and the subcutaneous tissue was dissected with electrocautery. The anterior rectus sheath was incised, and space was created behind the anterior rectus sheath and the rectus abdominis muscle. The pulse generator was sized and placed in the created pocket. Pacing leads were passed through a subcutaneous tunnel to reach the target site of device placement in the left hypochondrium. 

Step 3: Connection of Epicardial Leads and Pulse Generator

The pulse generator device was connected to the pacing leads. The device was placed in the created pocket. Pacemaker interrogation was performed, and the target heart rate and mode were set. The monitor was checked to confirm proper ECG spikes and rate. Any redundant parts of the lead wire may be left in the pleura or pericardial cavity. The pericardium was partly closed, and a left pleural drain was placed. The left lung was recruited, and hemostasis was achieved. The ribs were approximated with a polyester suture of appropriate size. The anterior rectus sheath was closed, and the subcutaneous layer and skin of both wounds were closed in layers. A sterile dressing was placed, and the patient was shifted to the ICU. The patient was extubated as soon as feasible. Any epicardial temporary pacing wires should be removed after the first interrogation 24 hours later. 

References

1. McLeod KA. Cardiac pacing in infants and children. Heart. 2010;96(18):1502–1508. doi: 10.1136/HRT.2009.173328.
2. Goldman BS, Hill TJ, Weisel RD, et al. Permanent pacing after open-heart sugery: acquired heart disease. Pacing ClinElectrophysiol. 1984;7:367–371.]
3. Singh HR, Batra AS, Balaji S. Pacing in children. Ann PediatrCardiol. 2013;6(1):46–51. doi: 10.4103/0974-2069.107234.
4. Silvetti MS. Pacemaker and implantable cardioverter defibrillator implantation in pediatric patients. Minerva Cardioangiol. 2007;55(6):803–813.
5. Patsiou V, Haidich AB, Baroutidou A, Giannopoulos A, Giannakoulas G. Epicardial Versus Endocardial Pacing in Paediatric Patients with Atrioventricular Block or Sinus Node Dysfunction: A Systematic Review and Meta-analysis. PediatrCardiol. 2023 Dec;44(8):1641-1648. doi: 10.1007/s00246-023-03213-x. Epub 2023 Jul 22. PMID: 37480376; PMCID: PMC10520152.
6. Hosseini MT, Popov AF, Kourliouros A, Sarsam M. Surgical implantation of a biventricular pacing system via lower half mini sternotomy. J Cardiothorac Surg. 2013 Jan 12;8:5. doi: 10.1186/1749-8090-8-5. PMID: 23311392; PMCID: PMC3599272.
7. Sako H, Hadama T, Shigemitsu O, Miyamoto S, Anai H, Wada T, Iwata E, Hamamoto H. An implantation of DDD epicardial pacemaker through ministernotomy in a patient with a superior vena cava occlusion. Pacing ClinElectrophysiol. 2003;26:778–780. doi: 10.1046/j.1460-9592.2003.00134_26_3.x.
8. Dodge-Khatami A, Kadner A, Dave H, Rahn M, Prêtre R, Bauersfeld U. Left heart atrial and ventricular epicardial pacing through a left lateral thoracotomy in children: a safe approach with excellent functional and cosmetic results. Eur J Cardiothorac Surg. 2005;28:541–545. doi: 10.1016/j.ejcts.2005.06.040.
9. Warner KG, Halpin DP, Berul CI, Payne DD. Placement of a permanent epicardial pacemaker in children using a subcostal approach. Ann Thorac Surg. 1999;68:173–175. doi: 10.1016/S0003-4975(99)00399-9.
10. Furrer M, Fuhrer J, Altermatt HJ, Ris H, Mettler D, Althaus U, Carrel T. VATS-guided epicardial pacemaker implantation. Hand-sutured fixation of atrioventricular leads in an experimental setting. SurgEndosc. 1997;11:1167–1170. doi: 10.1007/s004649900562.

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