|Year : 2022 | Volume
| Issue : 1 | Page : 62-64
Simple surgical technique for epicardial pacemaker wire preparation and insertion
Amit Mishra1, Kartik Patel2, Chandrasekaran Ananthanarayananh2, Vivek Wadhawa2, Himani Pandya3
1 Department of Pediatric Cardiovascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Center (Affiliated to B. J. Medical College), Civil Hospital Campus, Ahmedabad, Gujarat, India
2 Department of Cardiovascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Center (Affiliated to B. J. Medical College), Civil Hospital Campus, Ahmedabad, Gujarat, India
3 Department of Research, U. N. Mehta Institute of Cardiology and Research Center (Affiliated to B. J. Medical College), Civil Hospital Campus, Ahmedabad, Gujarat, India
|Date of Submission||30-Dec-2021|
|Date of Decision||21-Mar-2022|
|Date of Acceptance||25-Mar-2022|
|Date of Web Publication||26-Apr-2022|
Department of Pediatric Cardiovascular and Thoracic Surgery, U. N. Mehta Institute of Cardiology and Research Center (Affiliated to B. J. Medical College), New Civil Hospital Campus, Asarwa, Ahmedabad - 380 016, Gujarat
Source of Support: None, Conflict of Interest: None
Epicardial pacing wire (EPW) insertion is an integral part of open heart surgery. However, the use of EPW insertion is also associated with complications such as bleeding, tamponade, arrhythmias, and occasionally even death of the patient. Various techniques have been described for preparing, placing, and removing EPW. We present our simple, yet effective technique of preparing, inserting, and removing EPW where the incidence of complications is nil.
Keywords: Congenital heart block, epicardial pacing wires, Temporary pacing wire
|How to cite this article:|
Mishra A, Patel K, Ananthanarayananh C, Wadhawa V, Pandya H. Simple surgical technique for epicardial pacemaker wire preparation and insertion. J Pract Cardiovasc Sci 2022;8:62-4
|How to cite this URL:|
Mishra A, Patel K, Ananthanarayananh C, Wadhawa V, Pandya H. Simple surgical technique for epicardial pacemaker wire preparation and insertion. J Pract Cardiovasc Sci [serial online] 2022 [cited 2023 Jan 31];8:62-4. Available from: https://www.j-pcs.org/text.asp?2022/8/1/62/344139
| Introduction|| |
Epicardial pacing wire (EPW) insertion is an integral part of open heart surgery. However, the use of EPW insertion is also associated with complications such as bleeding, tamponade, arrhythmias, and occasionally even death of the patient. Various techniques have been described for the usage of EPW. Herein, we present our simple, yet effective technique of preparing, inserting, and removing EPW; with its use, the incidence of complications is nil.
| Technique|| |
Commercially disposable EPW is available with an insulating layer which encloses the wire which is supplied with a curved metallic needle, on the one end, for the passage through the myocardium and a straight needle, on the other end, for the passage through the chest wall [Figure 1]a.
|Figure 1: Technique showing preparation and placing of epicardial pacing wire. (a) Commercially available epicardial pacing wire. (b) The distal insulated portion of epicardial pacing wire is partially cut and “bared.” (c) Distal noninsulated pacing wire (with curved needle) is cut/excised|
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Under all sterile precautions, the insulated portion of the distal 1–1.5 cm of the EPW is circumferentially partially cut using 15 knives to expose the underlying metallic wire [Figure 1]b. The noninsulated wire along with its needle is cut from the base of the distal insulated portion [Figure 1]c. The partially cut insulated portion of the wire is now gently slid distally on the noninsulated wire for 2–3 mm [Figure 2]a. The distal insulated portion of EPW should be kept up to 5–8 mm, not longer. Consequent to this, the distal end of the EPW tip will now be covered by an insulated atraumatic material [Figure 2]a. Consequent to this, there will be 3–4 mm bare metal wire between the proximal and the distal insulated portion of the EPW [Figure 2]a. This bare noninsulated portion of the wire is atraumatic and can be fixed on to the myocardium with 6-0 or 7-0 proline suture [Figure 2]b and [Figure 3]. As a consequence of this, the distal portion of the wire is now fully covered with the insulated rubber/plastic sheath and is atraumatic to the adjacent structures [Figure 2]b and [Figure 3]. Because of the small portion of bare wire that is in contact with heart, threshold problem resulting from a larger area of contact is minimized. Hence, with this technique, there is no chance of any injury to any adjacent structures. The wires are removed by constant gentle traction, allowing the motion of the heart to assist the dislodgement. We have observed that the distal end of insulation is absent on removal of the wire. However, we have never observed any complication attributable to retained distal insulation cover, and we have never experienced a wire that could not be removed. All patients are subjected to 12-lead electrocardiogram following wire removal, and none of them had any ventricular arrhythmias.
|Figure 2: (a) After partial cut, the distal insulation ring is slightly pushed distally. (b) A suture fixes the noninsulated part of epicardial pacing wire to the myocardium|
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|Figure 3: Operative photograph showing fixed epicardial pacing wire on the right ventricle|
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| Discussion|| |
Epicardial pacing is often the best and sometimes the only method for treating temporary rhythm disturbances that often occur in the postoperative management of critically ill cardiac patients. There is a small but definite risk of injury to adjacent structures due to the placement of EPWs. Further, the removal of these wires postoperatively can potentially lead to serious bleeding episodes necessitating surgical intervention. Bougioukas et al. have reported in a series that the removal of EPW could be recognized as a definite cause of bleeding in eight cases of the total of 4244 patients (0.2%), accounting for 3.6% of all re-explorations for bleeding. The outcome in two patients was fatal, wherein the intraoperative findings confirmed acute pericardial hemorrhagic effusion. The other complications of EPW include infection, myocardial damage, ventricular arrhythmias, perforation, and tamponade.,
Several serious and somewhat bizarre complications have been described in the literature after the removal of EPW.,,, A major problem with all techniques of EPW placement is the development of an inflammatory reaction around the wire/myocardium interface, and EPW usually fails to sense and capture after 5–6 days. We have never come across issue with our technique. Only 2–3 mm (size of small clip) of distal covering of insulated part of pacing wire remains in the pericardial cavity. We have not encountered any problem due to this foreign body till now. We believe that our technique of placing EPW is atraumatic and does not create any inflammatory reaction within myocardium.
Every year, we perform nearly 5000 cardiac surgeries. We initially had complications due to injury to adjacent cardiac structures by EPW needing emergency re-explorations. For the past 12 years, we are using our modified technique for preparing and placing EPWs. With this modified technique, we have never had any re-exploration due to injury from EPW.
| Conclusion|| |
We conclude that our modified technique of preparing and fixing the EPW is very simple and safe and is free from any untoward complications.
Financial support and sponsorship
U.N. Mehta Institute of Cardiology and Research Centre supported the study.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bougioukas I, Jebran AF, Grossmann M, Friedrich M, Tirilomis T, Schoendube FA, et al
. Is there a correlation between late re-exploration after cardiac surgery and removal of epicardial pacemaker wires? J Cardiothorac Surg 2017;12:3.
Reade MC. Temporary epicardial pacing after cardiac surgery: A practical review. Part 2: Selection of epicardial pacing modes and troubleshooting. Anaesthesia 2007;62:364-73.
Carroll KC, Reeves LM, Andersen G, Ray FM, Clopton PL, Shively M, et al
. Risks associated with removal of ventricular epicardial pacing wires after cardiac surgery. Am J Crit Care 1998;7:444-9.
Dyal HK, Sehgal R. The catastrophic journey of a retained temporary epicardial pacemaker wire leading to Enterococcus faecalis
endocarditis and subsequent stroke. BMJ Case Rep 2015;2015:bcr2014206215.
Guerrieri Wolf L, Scaffa R, Maselli D, Weltert L, Nardella S, Di Roma M, et al
. Intraaortic migration of an epicardial pacing wire: Percutaneous extraction. Ann Thorac Surg 2013;96:e7-8.
Smith DE 3rd
, DeAnda A Jr., Towe CW, Balsam LB. Retroaortic abscess: An unusual complication of a retained epicardial pacing wire. Interact Cardiovasc Thorac Surg 2013;16:221-3.
Mahon L, Bena JF, Morrison SM, Albert NM. Cardiac tamponade after removal of temporary pacer wires. Am J Crit Care 2012;21:432-40.
[Figure 1], [Figure 2], [Figure 3]