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Having addressed equipment requirements and some of the early steps in the process of permanent pacemaker (PPM) implantation in part I of this two part series, this section continues with the rest of the PPM implantation procedure and some aspects of post-procedural management/care.
LEAD PLACEMENT TECHNIQUES
Before discussing lead placement itself, it is important to briefly explain the structure of a permanent pacing lead. The leads themselves are very floppy and intrinsically have very little stiffness. This means that as the lead is moved around, the tip moves freely without any significant ability to steer it. To overcome this there is a central lumen to the lead which will allow passage of a stiffer thin wire known as a “stylet”. The further the stylet is passed down the lead (potentially almost to the tip), the more of the lead body is stiffened (fig 1). These stylets may also be “reshaped” easily to allow the tip of the lead to be further steered in a specific direction (fig 1). It is important to keep this stylet clean and free of debris, particularly blood, as this can block the central lumen and prevents the stylet from passing far enough down the lead to give any useful support. Also, the different lead positioning techniques described below are not mutually exclusive. A competent operator will be comfortable with most of them to adapt to different situations, although they may have a preference for which one they use first. The fixation method of the lead also has important implications. Lead tips may fixate “passively” or “actively”. Passive fixation leads have “tines” at the end of the lead (fig 1) which act as an anchor to hold the lead tip in place acutely. Over a period of time (weeks to months) the tip of the myocardium around the lead …
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