Title : Implantation of permanent cardiac pacemakers with right-sided access in collaboration with a vascular surgeon: pro et contra
Abstract:
In our review, we wanted to highlight the advantages of implanting cardiac pacemakers on the right side of the chest, with the generator site below the right clavicle. This approach is not used as often as a method of implanting cardiac pacemakers today, but it has its advantages. We also wanted to highlight the advantages of collaboration between cardiologists and vascular surgeons, given that it is common practice today for cardiologists to perform cardiac pacemaker implantation independently. We would like to emphasize that in right-sided implantation of a cardiac pacemaker, the electrode position is in the shape of the letter "S", which means that the electrode bends into two contralateral curves, as opposed to left-sided implantation where the electrode has only one curve on its way from the generator to the right ventricle. With two electrode curves, we get better electrode stability and consequently fewer postoperative dislocations and electrode flotations in the right ventricle. Furthermore, in collaboration with a vascular surgeon, the benefit is in creating a deeper generator bed between the pectoralis major and minor muscles, which results in better generator stability, which correlates with fewer local decubitus ulcers and generator prolapse outside the skin, which usually occurs more often in thin patients and causes very unpleasant local infections. In this deeper implantation approach, in most cases, the venous system is reached via the cephalic vein, which is a tributary of the subclavian vein. This reduces the possibility of complications such as local hematomas caused by difficult and long-term punctures of the subclavian vein, especially in obese individuals and individuals with a barrelshaped thorax, and iatrogenic pneumothorax.
It is also worth emphasizing the aesthetic impression of deeper implantation, which is more acceptable given the smaller local protrusion of the generator, and thus the more naturalappearance of that part of the chest, which also contributes to better psychological acceptance of the electrostimulation system by the patient. As for the negative characteristics of our right approach, we can point out that the practicality of implantation on the left side of the chest, i.e. under the left clavicle, is more practical for right-handed people, who are the majority in the general population. Furthermore, our approach of creating a “deeper” bed for the generator requires much more detailed intraoperative hemostasis due to the more frequent postoperative hematomas, especially in patients who are on antiplatelet or anticoagulant therapy, or who are prone to hemorrhagic diathesis. Also, the “deeper” approach is more prone to the formation of adhesions, so sometimes it is more difficult to access the generator when replacing it when the battery is exhausted, and it is also possible to damage the electrode, which must also be prepared and mobilized for connection to a new generator. It is not unimportant to note that implantation performed independently by cardiologists is technically easier and faster to implement in organizational terms. In the end, we can conclude that when all the pros and cons of our method of implanting permanent heart pacemakers are considered, we can say that our approach has advantages that are useful to take into account, and cardiologists can look at them and assess for themselves what is better for their patient at a certain moment.
