Experience with a simple method of epicardialintramural pacer lead implantation on either ventricle using local anaesthesia for long term cardiac pacing in casesof symptomatic heart block ispresented. The report concerns 40 patients with 41 implants. The follow-up period was 6-19 months. There were 3 operative deaths. One ofthe deaths was coincidental and the other 2 were attributed to bad selection. Early electrode failure due to the development of an exit block occurred in 1 case; he has done well after his right ventricular electrode was transferred to the left ventricle through the same incision using local anaesthesia. There has been no late electrode failure. Nearly all the survivors have obtained excellent results. The distinct advantages offered by this technique of epicardial pacing are discussed. The mod$cation which has been introduced in extending the scope of pacer lead implantation to the left ventricle has increased the usefulness of the technique. Left ventricular placement of the electrode assures better intramural pacing.
Breakage of a pacer lead due to the pacemaker-twiddler's syndrome (PTS) occurred in 4 of 62 survivors following epicardial-intramural pacer lead implantation with the pulse generator placed in each case in a subcostal left upper quadrant subcutaneous pocket. The abdominal pulse generator pocket appears to invite spontaneously occurring PTS, more so in a pregnant woman. The important predisposing factor to the development of PTS is an excessively spacious pulse generator pocket containing a pool of fluid. Addition of a few simple modifications to the technique of cardiac pacing would prevent the complication; these include implantation of the pulse generator in a plane deeper to the pectoral muscles, suspending the pulse generator from the clavicle and application of vacuum-suction drainage to the generator pocket in the initial phase of wound healing. In the presence of an optimally fitting pulse generator pocket, PTS should be rare with subclavicular subpectoral pulse generator implantation without active patient participation. The syndrome may not be as rare a cause of pacer lead malfunction as may appear from the relative paucity of reports in the literature.
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