3. Early complications of pacemaker
implantation
– Pneumothorax/Hemothorax/vascular
hemorrhage/AIR Emboli
– SVT, VT/ Cardiac arrest
– Lead dislodgement/Lead perforation
4. Pneumothorax
• Absence of lung markings over the lung
field ipsilateral to the pacemaker pocket
assessed from the fluoroscopy or pre-
discharge x-ray.
• Non-puncture related, might occur at
contralateral side
6. Pneumothorax
• 0.66% (190/28,860 patients) in Danish Pacemaker
Register
– more often in women [OR 1.9],
– age >80 years [OR 1.4],
– prior history of chronic obstructive pulmonary disease
[OR 3.9]
– implantation of a dual-chamber PM [OR 1.5]
– venous access with subclavian vein puncture [OR 7.8]
– venous access with both subclavian vein puncture and
cephalic vein cut-down [OR 5.7]
– implantation in a non-university center [OR 2.1].
9. How to avoid pneumothorax
• The cephalic vein cut-down technique
should be applied whenever possible to
avoid this complication.
10. Pneumothorax nursing care
• Administer oxygen as prescribed.
• Position the client in high fowler’s position.
• Prepare for chest tube placement until the lung
has expanded fully.
• Monitor chest tube drainage system.
13. Air Emboli
• More occurs in
– Un-cooperated patients
– Under respiratory distress
– Old age
– Snoring patients
• Management
– IV resuscitation
– Raise patients’ legs
– Increase FiO2
19. Anticoagulation therapy
• Warfarin was temporarily discontinued before device
implantation when possible to achieve an INR value
of < 1.7
• Administration of LMWH was stopped 24 h before the
procedure
• Antiplatelet therapy with ASA or clopidogrel was
allowed to continue
• Treatment with warfarin was resumed after 24 h and
with LMWH after 12–24 h
21. Lead related complications
1. Lead dislodgement
Atrial > Ventricular
2. Lead fracture
3. Loss of integrity of insulation
22. Lead failure
• Development of high pacing thresholds
or sensing problems resulting in the
need to program the device to a
different pacing mode or the need for
reoperation.
27. Lead Dislodgement
Diagnostic features
– changes in the morphology of
capture beats
– changes in dipole of the
pacing stimulus
– changes in the lead position
identified on a chest
radiograph
28. Lead Dislodgment
Treatment
– surgical intervention to reposition the lead
• an adequate heel on the intracardiac portion of the lead
• look for a 2 to 3mV current of injury pattern
• electrical and mechanical stability of the lead may be
assessed
– Twiddler’s syndrome
• the portion of the lead within the pocket should be
carefully inspected.
• If damage to the conductor coil or insulation is noted, the
lead should not be reused.
29. Order a Chest X-ray
The chest x-ray revealed a dislodged lead
40. Undersensing . . .Overpacing
• Pacemaker does not “see” the intrinsic
beat, and therefore does not respond
appropriately
Intrinsic beat
not sensed
Scheduled pace
delivered
VVI / 60
41. Inhibition of the pacemaker by events
pacemaker should ignore, e.g. EMI,
T-waves and myopotentials
Oversensing
42. Oversensing
Possible Causes Corrective Measures
•Fractured/dislodged lead •Replace/reposition lead
•Environmental interference •Eliminate interference
•T-wave oversensing •Sensing test/decrease sensitivity
•Faulty cable connections •Check connections
43. Oversensing …Underpacing
• An electrical signal other than the
intended P or R wave is detected
Marker channel
shows intrinsic
activity...
...though no
activity is present
VVI / 60