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Implantation of transvenous pacemakers in infants and small children
J E Molina1, A C Dunnigan, J E Crosson
1Division of Cardiovascular and Thoracic Surgery, University of Minnesota, Minneapolis 55455.
Insights
This study details a specialized protocol for transvenous pacemaker implantation in pediatric patients, emphasizing vein assessment and lead selection to ensure device success in growing children.
Area of Science:
- Pediatric Cardiology
- Biomedical Engineering
- Interventional Cardiology
Background:
- Transvenous pacemaker implantation in children presents unique challenges due to anatomical variations and growth.
- Small vein size and thin subcutaneous tissue require tailored approaches for pediatric pacemaker systems.
Purpose of the Study:
- To describe a standardized five-point protocol for transvenous pacemaker implantation in infants and children.
- To outline strategies for managing anatomical considerations and growth in pediatric pacemaker recipients.
Main Methods:
- A strict five-point protocol including duplex assessment, active fixation leads, short leads, secure generator anchoring, and lateral approach.
- Age-based selection of implantation route (internal jugular vein for younger children, subclavian veins for older children).
- Evaluation of vein diameter requirements for single and dual lead pacemaker systems.
Main Results:
- The protocol addresses critical factors: small subclavian vein size, thin chest subcutaneous layer, and patient growth.
- Internal jugular vein access was used in all children under 3 years and 50% of those aged 4-7 years.
- Short leads and the lateral approach were employed to minimize complications and bulk.
Conclusions:
- A meticulous, age-appropriate protocol is essential for successful transvenous pacemaker implantation in pediatric patients.
- Duplex ultrasound assessment is crucial for determining the optimal implantation route.
- The described methods facilitate safe and effective pacemaker implantation, accommodating pediatric growth and anatomical constraints.
Abstract:
A series of 14 infants and small children ranging from 7 months to 7 years in age (mean, 2.5 years) underwent implantation of transvenous pacemaker systems. Three factors are of utmost importance in children: small subclavian vein size, thin subcutaneous layer in the chest, and growth. A five-point protocol is followed strictly: (1) duplex assessment of upper veins, (2) use of active fixation leads, (3) use of short (36 to 45 cm) leads, (4) anchoring of pulse generator with nonabsorbable material to prevent migration, and (5) routine use of the "lateral approach" in children more than 2 years old when the pulse generator is implanted in the chest. Because lead diameters measure 2 to 2.3 mm, a one-lead system needs a vein diameter of 5 mm (cross-sectional area of 19 mm2). A two-lead system needs a vein at least 7 mm in diameter and a cross-sectional area of 38 mm2 to prevent vein occlusion. Therefore all children less than 3 years of age had the leads implanted via the internal jugular vein. In 50% of children between 4 and 7 years of age, the internal jugular system also was used. Children more than 7 years old have leads implanted via the subclavian veins. Duplex ultrasound assessment of the upper veins is important to decide route of implantation. Use of short leads is recommended to reduce bulk at the pulse generator site. The "lateral approach" prevents problems at the generator implantation site.