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Pacemaker implantation: Best practices

Raja Selvaraj
Professor of Cardiology
JIPMER

Antiplatelets

  • Aspirin can be continued
  • Clopidogrel monotherapy - Continue if necessary
  • Ticagrelor - Change to Clopidogrel if possible, interrupt if possible
  • DAPT - Change to Aspirin alone when possible
  • DAPT with recent PCI - defer device implant if possible
  • Restart in 24-48 hours

Anticoagulants

  • No Heparin bridging
  • Warfarin - Interruption, Uninterrupted with lower INR, Uninterrupted
  • NOAC - Interruption, Uninterrupted

Bruise control - Bridging

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Birnie DH, Healey JS, Wells GA, et al. Pacemaker or defibrillator surgery without interruption of anticoagulation. N Engl J Med. 2013;368(22):2084-2093. https://doi.org/10.1056/NEJMoa1302946.

Bruise control 2 - Interruption

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Birnie DH, Healey JS, Wells GA, et al. Continued vs. interrupted direct oral anticoagulants at the time of device surgery, in patients with moderate to high risk of arterial thrombo-embolic events (BRUISE CONTROL-2). Eur Heart J. 2018;39(44):3973-3979. https://doi.org/10.1093/eurheartj/ehy413

Antibiotic

  • Cefazolin
  • Single dose
  • Within 1 hour
  • Complete before skin incision

Active vs passive leads

  • More choice of site
  • Less dislodgement
  • Increase in perforation ?

Active vs Passive leads

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Karampinos, K., Zagoridis, K., Sideris, K. et al. Active versus passive fixation leads in cardiac implantable devices: a meta-analysis of post-discharge cardiac perforation and lead dislodgement risk. J Interv Card Electrophysiol (2026). https://doi.org/10.1007/s10840-026-02383-x

Venous access

  • Cephalic vein cutdown
  • Axillary vein puncture
  • Subclavian vein puncture

Venous access

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Anagnostopoulos I et al. Different venous approaches for implantation of cardiac electronic devices. A network meta-analysis. Pacing Clin Electrophysiol. 2022 Jun;45(6):717-725. doi: 10.1111/pace.14510.

Venous access - Ultrasound guided

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Vitali F et al. Ultrasound-Guided Venous Axillary Access Versus Standard Fluoroscopic Technique for Cardiac Lead Implantation: ZEROFLUOROAXI Randomized Trial. JACC Clin Electrophysiol. 2024 Mar;10(3):554-565. doi: 10.1016/j.jacep.2023.11.020.

Air embolism

  • Hydration
  • Trendelenburg position
  • Pinch sheath

RV lead placement

  • Avoid inadvertent LV placement
  • Prefer septal lead placement

3D Mond curve

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Confirming true septal placement

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Confirming true septal placement

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Pocket

  • Position medially
  • Correct plane

Role of antibiotic envelope

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Tarakji KG … Wilkoff BL; WRAP-IT Investigators. Antibacterial Envelope to Prevent Cardiac Implantable Device Infection. N Engl J Med. 2019 May 16;380(20):1895-1905. doi: 10.1056/NEJMoa1901111.

Antibiotic envelope

  • First CRT-D implant
  • Generator change with higher infection risk
  • Device upgrade
  • Lead / Pocket revision

Suturing

  • Interrupted vs continuous
  • Subcuticular absorbable vs External non-absorbable
  • Non braided monofilament for skin
  • Staples / Skin glue

Post procedure

  • Early ambulation
  • Reduce immobilisation
  • Antibiotics not needed

Pre discharge

  • Counseling
  • Device interrogation

Pacemaker implant complications

  • FOLLOWPACE
    • 12.4% at 2 months
  • MOST
    • 4.8% in 30 days
    • 7.5% in 3 years
  1. Udo EO et al. Incidence and predictors of short- and long-term complications in pacemaker therapy: the FOLLOWPACE study. Heart Rhythm. 2012 May;9(5):728-35. doi: 10.1016/j.hrthm.2011.12.014.
  2. Ellenbogen KA. Complications arising after implantation of DDD pacemakers: the MOST experience. Am J Cardiol. 2003 Sep 15;92(6):740-1. doi: 10.1016/s0002-9149(03)00844-0.

Self Audit

  • Early infection - 0.3% (< 6 mths)
  • Late infection - 1% (6 mths - 5 yrs)
  • Lead related reintervention - 2.5% (5 yrs)

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