Surgical Implantation of Cardiac Rhythm Devices

261 Pages·2017·99.416 MB·English

by  Jeanne Poole, Lyle W. Larson

Surgical Implantation
of Cardiac Rhythm Devices
Editors
Jeanne E. Poole, MD
Lyle W. Larson, PA-C, PhD
Associate Editor
Brian Olshansky, MD

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SURGICAL IMPLANTATION OF CARDIAC RHYTHM DEVICES ISBN: 978-0-323-40126-5
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Library of Congress Cataloging-in-Publication Data
Names: Poole, Jeanne E., editor. | Larson, Lyle W., editor.
Title: Surgical implantation of cardiac rhythm devices / [edited by] Jeanne
E. Poole, Lyle W. Larson.
Description: Philadelphia, PA : Elsevier, [2018] | Includes bibliographical
references and index.
Identifiers: LCCN 2016028003 | ISBN 9780323401265 (hardcover : alk. paper)
Subjects: | MESH: Cardiac Resynchronization Therapy--methods | Cardiac
Resynchronization Therapy Devices | Arrhythmias, Cardiac--surgery
Classification: LCC RC684.E4 | NLM WG 166.5.C2 | DDC 617.4/120645--dc23 LC record
available at https://lccn.loc.gov/2016028003
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Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1

This book is dedicated to the electrophysiology and
surgical faculty, laboratory and surgical staff, and
fellows with whom we have worked and learned
from throughout our careers.
Contributors
Nazem Akoum, MD, MS Joanna M. Davies, MB BS, FRCA
Associate Professor Associate Medical Director, Professional Affairs
Director, Atrial Fibrillation Program Chief of Staff Elect
Department of Cardiology University of Washington Medical Center;
University of Washington Associate Professor
Seattle, Washington Department of Anesthesiology & Pain Medicine
University of Washington School of Medicine
Ulrika Birgersdotter-Green, MD Seattle, Washington
Professor of Medicine
Division of Cardiology Corinne L. Fligner, MD
University of California, San Diego School of Medicine Professor of Pathology
La Jolla, California Adjunct Professor of Laboratory Medicine
University of Washington
Roger Carrillo, MD, MBA Seattle, Washington
Chief of Surgical Electrophysiology
Cardiothoracic Surgery Marye Gleva, MD
University of Miami Professor of Medicine
Miami, Florida Electrophysiology Section
Department of Medicine
Frank Cecchin, MD Division of Cardiology
Professor of Pediatrics Washington University in St. Louis
Pediatric Cardiology St. Louis, Missouri
New York University
New York, New York Rakesh Gopinathannair, MA, MD, FAHA, FHRS
Director of Cardiac Electrophysiology
John I. Clark, PhD Associate Professor of Medicine
Professor and Chair Division of Cardiovascular Medicine
Department of Biological Structure University of Louisville
School of Medicine Louisville, Kentucky
University of Washington
Seattle, Washington Chris Healy, MD
Cardiac Electrophysiology Fellow
Judy M. Clark, PhD Cardiac Electrophysiology
Research Scientist University of Miami
Department of Biological Structure Miami, Florida
School of Medicine
University of Washington Joshua Hermsen, MD
Seattle, Washington Assistant Professor of Cardiothoracic Surgery
Associate Surgical Director of Adult Congenital Heart Disease
Christine Cramer-Mitchell, RN Department of Surgery
Cardiac Electrophysiology University of Washington
University of Washington Medical Center Seattle, Washington
Seattle, Washington
vi
Contributors vii
Charles B. Huddleston, MD Jeanne E. Poole, MD
Professor of Surgery Department of Medicine
Saint Louis University University of Washington
St. Louis, Missouri Seattle, Washington
Lyle W. Larson, PA-C, PhD Paul Pottinger, MD, DTM&H
Teaching Associate Associate Professor of Medicine
Division of Cardiology Division of Allergy and Infectious Diseases
University of Washington University of Washington
Seattle, Washington Seattle, Washington
Otway Louie, MD Jordan M. Prutkin, MD, MHS
Associate Professor of Surgery Associate Professor of Medicine
Division of Plastic Surgery Division of Cardiology
University of Washington University of Washington
Seattle, Washington Seattle, Washington
Stefan Lombaard, MBChB, FANZCA Melissa Robinson, MD, FHRS, FACC, CCDS
Assistant Professor Clinical Associate Professor of Medicine
Department of Anesthesiology Director of the Complex Ablation Program
University of Washington School of Medicine Medical Director of Electrocardiography Services
Seattle, Washington University of Washington
Seattle, Washington
Linda Marriott, MS, ARNP
Nurse Practitioner G. Alec Rooke, MD, PhD
Department of Electrophysiology Professor
University of Washington Department of Anesthesiology & Pain Medicine
Seattle, Washington University of Washington
Seattle, Washington
Brian Olshansky, MD
Professor Emeritus Andrea M. Russo, MD
Department of Internal Medicine Professor of Medicine
University of Iowa Hospitals and Clinics Division of Cardiology
Iowa City, Iowa Cooper Medical School of Rowan University
Camden, New Jersey
Kristen K. Patton, MD
Associate Professor of Medicine
Department of Medicine
Division of Cardiology
University of Washington
Seattle, Washington
Preface
Electrophysiology has evolved into a procedure-based subspe- An accompanying chapter details transvenous lead placement,
cialty. A wealth of literature exists addressing arrhythmia recog- including leads for rescynchronization pacing. Two additional
nition and treatment, including catheter-based ablations and chapters discuss considerations for novel and alternative lead
appropriate cardiac rhythm device choice and programming. placement, including epicardial leads and the totally intra-
Few texts provide an in-depth description of surgical tech- cardiac pacemaker, and implantation of the subcutaneous
niques. While physicians desiring to learn implant techniques implantable defibrillator. Challenges in pediatric and young
can refer to standard surgical texts for many common prin- adult patients are discussed, followed by a description of the
ciples, we considered that a surgical technique–focused text for procedural management of patients with special circum-
electrophysiologists was needed. stances and obstacles (e.g., obesity, cachexia, breast implants).
Electrophysiologists historically learned their surgical tech- A chapter on pitfalls and complications addresses mitigation
niques from surgical colleagues. However, as implantation of of the risks and management of the complications commonly
pacemakers and implantable cardioverter-defibrillators (ICDs) encountered in device implantation. One chapter is dedicated
transitioned from the surgeon to the electrophysiologist, to the important topic of prevention, evaluation, and man-
younger physicians have been further removed from formal agement of implantable device infections. A final chapter
surgical training. With each successive generation of trainees, reviews the postoperative management of patients undergoing
it may become more confusing to differentiate between fun- device implantation from the immediate postoperative period
damental technique and personal style or bias. Consequently, through discharge and follow-up.
trainees may or may not have had the opportunity to learn We offer a comprehensive compendium of the informa-
proper surgical technique or to adapt the procedure to various tion needed to successfully implant pacemakers and ICDs.
challenges that may be encountered in an individual patient. Collectively, it is our goal to provide trainees, recent gradu-
Surgical Implantation of Cardiac Rhythm Devices was written ates, and experienced implanting physicians the resources
with this in mind. and knowledge needed to augment their skills in device
This text begins with a historical overview of pacemaker and implantation.
ICD development. This is followed by a comprehensive review Surgical Implantation of Cardiac Rhythm Devices represents
of surgical anatomy specific to device implantation, including the culmination of 30 years of experience working with, and
relevant anatomic structures and landmarks. A review of surgi- learning from, the experiences of 15 fellow cardiac electro-
cal tools and techniques is provided to familiarize the electro- physiologists and 26 cardiothoracic surgeons at the University
physiology trainee with the tools of the trade and their proper of Washington. While we have asked many of our faculty at
use, suture and needle choices, and hemostasis. A chapter on the University of Washington to contribute to this effort, we
cardiac anesthesia is provided as a resource for those unfamiliar also sought the expertise of several colleagues throughout the
with the complexities of periprocedural analgesia and anesthe- United States. We appreciate their contributions. It is our hope
sia specific to the cardiac patient. A chapter reviewing radia- that the readers of this text will find the information comple-
tion safety is included as a reminder of the risks of radiation mentary to their mentored learning.
exposure to the patient, operator, and support staff, and how Finally, we give special thanks to Edward Verrier, MD,
to mitigate the risks of exposure. We also include a discussion Professor, Department of Surgery, University of Washington,
of proper patient preparation, procedural planning, patient for his support and to the many cardiothoracic surgical faculty
positioning, skin preparation, and draping. This is followed and staff who have collaborated with the electrophysiologists at
by a detailed description of the surgical procedure, including the University of Washington.
surgical planning, incision choices, pocket formation, vascular
access, lead positioning and fixation, securing of the lead(s) Jeanne E. Poole, MD
within the pocket, generator positioning, and wound closure. Lyle W. Larson, PA-C, PhD
viii
1
Development of Cardiac Implantable
Electrical Devices
RAKESH GOPINATHANNAIR, BRIAN OLSHANSKY
Introduction
In 1889, John Alexander McWilliam reported brilliant
A remarkable collaborative and forward-thinking effort led work that showed electrical impulses could cause ventricular
to the development of cardiac implantable electrical devices contraction (Fig. 1.1). He stated:
(CIEDs), which can stimulate the heart to beat, protect against
The heart was inhibited by stimulation of the vagus nerve in the
cardiac arrest, monitor physiologic parameters and arrhyth- neck, and then a periodic series of induction shocks (regulated
mias, and improve and forestall heart failure. Some key events by a metronome) was applied to the apex of the ventricles.… A
that led to modern CIEDs and their implantation are described series of single induction shocks excites a corresponding series of
here with a look toward the future. cardiac beats; the ventricular contraction precedes the auricular
contraction when the exciting shocks are applied to the ventri-
Where Did It Start? cles. Each systole causes the ejection of a considerable amount of
blood into the aorta and pulmonary artery, and a marked rise of
the blood-pressure at each beat.6
Myths and science converge in the initial attempts at cardiac
stimulation. The rather dubious beginnings are hard to estab- Although early experiences were not uniformly successful,
lish precisely, considering the naivety regarding mechanisms by 1927, Marmrostein had found a way to electrically stim-
and lack of documentation and peer review. Initial observa- ulate a dog’s heart.7 Soon thereafter, human cardiac pacing
tions occurred before electricity was understood fully and emerged. Mark Lidwell, an Australian physician, is consid-
before wall power. Nevertheless, cardiac stimulation began ered one of the fathers of modern pacing. In 1928, with alter-
hundreds of years ago, if not long before that, first mechani- nating current and a needle inserted into a ventricle, he used
cally, then electrically. intermittent electrical stimulation to resuscitate a child born
William Harvey made an arrested pigeon’s heart beat with with a cardiac arrest.8 To extend these initial observations,
the flick of a finger.1–3 Physicist Nickolev Abildgaard realized in 1932, Albert Hyman, a cardiologist working at the Beth
that electrical shocks could cause a hen to collapse but addi- David Hospital in New York, utilized a needle he called a
tional shocks brought it “back to life.”4 By the 1900s, electrical “pace-maker” to create an injury current in the heart (“intra-
currents were seen to start and stop ventricular fibrillation.5 cardiac” therapy) to allow it to beat again. In collaboration
Rudimentary electrical resuscitative device attempts for ambu- with his engineer brother, C. Henry Hyman, he developed
lances, however, initially met with little success. a spring-wound, hand-cranked stimulating motor he called
an “artificial pacemaker.”2 The mechanism was simple, but
Birth of the Pacemaker it worked and was used 43 times with success in 14 patients
(Fig. 1.2). Based on the need for increasing heart rates dur-
Astounding observations lent credence to the concept that elec- ing hypothermic procedures, Wilfred Bigelow, working with
tricity affected the heart (Table 1.1). In one instance, a child John A. Hopps, an electrical engineer, developed a transve-
who drowned was resuscitated by attaching one electrode to the nous catheter electrode that was placed in the heart and acti-
leg while rhythmically tapping the heart with another (Duch- vated using an external stimulator.1
enne de Boulogne, 1806–1875). Why this was attempted is Further development halted for quite some time when,
not clear. In another instance, electrical cardiac stimulation was in 1951, Boston cardiologist Paul Zoll developed an external
seen to affect heart rate directly in a woman who had a chest (transcutaneous) pacemaker that could stimulate the heart
tumor removed, leaving her heart exposed (H. von Ziemssen, but required 50 to 150 V of alternating current delivered via
1829–1902). Unfortunately, stimulation attempts may have external metal electrodes strapped to the chest (Fig. 1.3). It was
resulted in her death. painful and caused skin burns. The longest period of pacing
1
2
Surgical Anatomy for the
Implanting Physician
CORINNE L. FLIGNER, JOHN I. CLARK, JUDY M. CLARK, LYLE W. LARSON,
JEANNE E. POOLE
Introduction anterior axillary lines. These are easily observed by having
a person extend his or her arm and push down on a fixed
Anatomy, one of the oldest basic medical sciences, is defined object. The contraction of the latissimus dorsi and the pecto-
by three-dimensional structures, functions, and relationships ralis major raises two folds posterior and anterior to the axilla.
of organs and their blood supply, innervation, and lymphat- The posterior axillary line is the raised lateral boundary of the
ics.1–3 A comprehensive knowledge of human anatomy and contracting latissimus dorsi, the anterior axillary line is the
the surrounding structures is fundamental to the planning and raised lateral boundary of the contracting pectoralis major,
execution of a successful surgical procedure. In this regard, and the midaxillary line is vertically oriented in the center of
implantation of cardiac implantable electronic devices (CIEDs) the hollow axilla (Fig. 2.3).
(pacemakers and implantable cardiac defibrillators) is similar
Clinical Correlations
to any other surgical procedure. This chapter provides a review
of surgically relevant anatomy to the practitioner implanting • Th e chest wall landmarks dictate the boundaries of the sur-
these devices and highlights those features which are of clini- gical sites for device implantation. It is critical to under-
cal importance. Static and dynamic relationships of structures stand the interstructural relationships in both the supine
are emphasized, as are their appearances on radiographs when and standing positions.
appropriate. Illustrated anatomy and cadaveric dissections are
used to emphasize the relationship of anatomy to the procedure. Skin
External Anatomic Landmarks The surgical procedure starts at the skin, the largest single
organ in the body. While seemingly simple, the skin is a com-
The implanting physician should be familiar with the external plex protective barrier for the body with a rich network of
landmarks of the human thorax. The skeletal landmarks on vasculature, lymphatics, and nerves that supply sweat glands,
the surface of a patient guide the surgeon to the locations of sebaceous glands, hair follicles, and the sequential sensory der-
the important musculature and vasculature providing the basic matomes of the body wall (Fig. 2.4). The surface layer of the
framework for the surgical space. Fig. 2.1 shows the important skin is the epidermis, consisting of the stratum corneum, mela-
superficial anatomic landmarks of the anterior chest wall. The nocytes, and Langerhans cells (which participate in the skin’s
skeletal boundaries of the chest include the clavicles, manubrium, immune response). The underlying dermis is a thick layer of
sternum, xiphoid process, and rib cage. Critical anatomic associa- fibrous and elastic tissue (made up of collagen, elastin, and
tions include the clavicular and sternal attachments of the pec- fibrillin) that gives skin its flexibility and strength. The dermis
toralis major muscle and the deltopectoral groove, a depression also contains sensory nerve endings and capillaries. Pain, itch,
between the lateral edge of the pectoralis major muscle (clavicular and temperature are sensed by the unmyelinated nerve end-
head) and the medial border of the anterior deltoid muscle. ings in the papillary dermis. Low stimulation causes itching,
The spinal column, scapulae, and ribs compose the pri- whereas high stimulation causes pain. Scratching converts itch-
mary bony landmarks of the posterior chest wall (Fig. 2.2). ing to the more tolerable sensation of pain.
The posterior musculature includes the trapezius and latis- The subcutaneous collagen fibers of the dermis course
simus dorsi. The lateral aspect of the external body wall can along specific directional lines, referred to as Langer’s lines
be separated into vertical regions: the posterior, mid-, and (Fig. 2.5).4,5 Other “lines” have been identified and include
13