A method of permanent transvenous implantation of an atrial electrode

Experimental and laboratory

A method

of permanent

of an atrial

reports

transvenous

implantation

electrode

I. Richard Zucker, M.D.* Victor Parsonnet, M.D.** Lawrence Gilbert, M.D.*** Newark, N. J.

T

ransvenously implanted atria1 electrodes frequently become dislodged. This is one reason why potentially valuable pacemakers, such as atria1 synchronous or atria1 ventricular sequential units, have not been used more widely. An electrode may be held tightly to the atria1 wall by a direct physical bond, such as a barb or hook. Vogel and associates’ and Bleifeld and co-workers2 used such a device with some success. An electrode placed in the coronary sinus may be used to pace the atrium, but stimulation thresholds are higher than by direct atria1 implants.3 Lagergren and colleagues4 attached electrodes to the external atria1 wall through a mediastinoscope, but this method may be too difficult for general use. The use of J-shaped wires has been reported by Smyth and associates5 and by De Sanctis,6 but these wires, despite the relative ease of insertion, may become dislodged easily and as yet these have not gained wide acceptance. Recently J leads have been marketed by

both the Cordis and the American Optical Companies (Fig. 1). The fixed curve of the lead is intended to force the electrode against the atria1 wall where it will eventually become fixed by a developing fibrous capsule. We have devised a procedure to place the tip of the J lead in the right atria1 appendage by the following technique. Method An appropriate vein of the upper torso is selected. For simple atria1 pacing we use the cephalic vein. When two electrodes are needed, as in atria1 synchronous and atrioventricular sequential pacemakers, we use the cephalic vein for the ventricular electrode(s), and the ipsilateral external jugular vein for the atrial. (On one occasion we inserted one lead through the cephalic vein and the other through the subclavian vein, thereby making only one incision, but here the surgical technique was somewhat more difficult.) When a double electrode system is used, the ventricular electrode is inserted in the

From the Department of Surgery and Cardiodynamics of the Newark Beth Israel Medical Center, Newark, N. J. Received for publication March 15. 1972. Reprint requests to: Victor Parsonnet. M.D., Newark Beth Israel Medical Center, 201 Lyons Ave.. Newark. N. J. 07112. *Director of Cardiodynamics of the Newark Beth Israel Medical Center. Newark, N. J. **Director of Surgery of the Newark Beth Israel Medical Center, Newark, N. J., and Clinical Professor of Surgery of The College of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark. N. J. **Director of Thoracic Surgery of the Newark Beth Israel Medical Center. Newark, N. J.. and Associate Professor of Surgery. The College of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, N. J.

Vol. 85, No. 2, pp. 195-198

February, 1973

American Heart Journal

195

196

Zucker,

Fig.

1,

Parsonnet,

A and B. Photograph

Am. Heart I. February, 1973

and Gilbert

of Cordis

(A) and American

Optical

(B) J-shaped

atria1

electrodes.

Fig. 2, A and 23. Two frames taken during cinefluoroscopy of the heart. The tip of the atria1 bipolar electrode is in the atria1 appendage, and can be seen at the two extremes of its position as the atrium contracts (A and 9). A temporary right ventricular bipolar electrode lead lies along the right atria1 border.

usual fashion. Excitation threshold levels are determined. The atria1 lead is then introduced with its stiffening stylet in place until the tip lies in the distal right atrium just above the inferior vena cava. The stylet is then withdrawn, and with a little manipulation the J curve will reset itself with the tip pointing cephalad. The lead is then pulled upward, with the tip of the J anterior and slightly to the left, until

it enters and becomes lodged in the atria1 appendage. At that point the J loop begins to straighten out slightly. The most important clue to proper positioning will be swaying of the tip from side to side with each atria1 contraction (Figs. 2 and 3). If there is no spontaneous atria1 activity, movement can be produced by pacing of the atrium through the electrode. Excitation thresholds are then mea-

Permanent

trunsvenous

Fig. 3, A and B. Line drawings A and B illustrate

implantation

approximate

of atrial electrode

anatomic relationships

197

seen in Fig. 2.

Fig. 4, A and B. Posteroanterior (A) and lateral (B) x-rays of the chest in a patient with a transvenously implanted bifocal demand American Optical pacemaker. (The films have been retouched for illustrative clarity.)

198

Zucker,

Parsonnet,

Table I. Follow-up in 14 patients

of electrode placement

No. of patients Schaldach hook J-wire, Cordis American Optical Totals

Am. Heart 3. February, 1973

and Gilbert

2 4 8

14

Disfilaced 0 0 0 0

sured.* For most electrodes, acute thresholds in the atria1 appendage are higher than in the ventricle, usually ranging from 1.0 to 1.5 volts, and 1.5 to 2.0 milliamperes with electrodes of conventional size. After the leads are in place, they are both rechecked electrically and fluoroscopically to assure that placement of the second did not dislodge the first. We have found it simpler to place the ventricular electrode first, because the ventricles can be controlled during insertion of the second electrode, and because dislodgment of the ventricular electrode by manipulating the atria1 electrode is unlikely to occur. Upon completion of the pacemaker insertion, posteroanterior and lateral chest x-rays are taken to confirm the proper anatomical position. The tips will appear to be far anterior (Fig. 4). Results

We have utilized this technique in 14 cases. The electrodes have been followed *We

have threshold

described our method of measurement of excitation elsewhere, and regard it as one of the most important ingredients of proper electrode placement.7-9 The amplitude of the P and R wave signals are also recorded. but this step is of lesser importance.

for 3 to 49 months, with an average followup of 17 months (Table I). Sensing with one of the Cordis units was intermittent during the first few weeks of insertion, but at eight months the atria1 synchronous pacemaker is functioning normally. No electrodes have become dislodged. Conclusion

A method of insertion of a J-shaped atria1 electrode has been described that is relatively simple and reliable. Secure transvenous electrode placement will permit wider use of pacemakers that require an atria1 lead. REFERENCES 1. Vogel, I., Dressler, L., Witte, J., Warnke, H., Porstmann, W., and Schaldach, M.: Atria1 synchronized pacing using a new transvenous technique, Ann. Cardiol. Angeiol. 20:381, 1971. 2. Bleifeld, V., Irnich, W., and Efferts, S.: A new transvenous electrode with myocardial fixation for permanent pacing. Digest Ninth International Conference of Medical and Biological Engineering, Melbourne, Australia, 1971, p. 76. 3. Kramer, D. H., and Moss, A. J.: Permanent pervenous atria1 pacing from the coronary vein, Circulation 42:427, 1970. 4. Lagergren, H., Johansson, L., Karlof, I., and Thornander, I-I.: Atrial-triggered pacemaking without thoracotomy: Apparatus and results in twenty cases, Acta Chir. Stand. 132:678, 1966. 5. Smyth, N. P., Keshishian, J. M., Basu, A. P., Bacos, J. M.. Massumi, R. A., Fletcher, R. D., and Baker, N. R.: Permanent transvenous synchronous cardiac pacing, Ann. Thorac. Surg. 11:360, 1971. 6. DeSanctis, R. W.: Diagnostic and therapeutic uses of atria1 pacing, Circulation 43:748, 1971. 7. Parsonnet, V., Zucker, I. R., Gilbert, L., Brief, D. K., and Alpert, J.: Implantable transvenous pacemakers: A two and one half year evaluation, Dis. Chest 53:247, 1968. 8. Parsonnet, V.: A decade of permanent pacing of the heart, Cardiovasc. Clin. 2 (2):182, 1970.