Permanent pacemakers are required by patients who have an extremely slow heart rate (bradycardia) and these devices are inserted under local anaesthesia and sometimes minimal sedation. The pacemaker is inserted into the subcutaneous leads, just below the clavicle (collar bone) and the leads are put through the cephalic view when a cut-down is done or through the sub-clavian view when it is by puncture technique.
Different types of pacemakers are used for different patients as per their individual requirements. Some patients receive a single lead pacemaker, with the lead put either into the atrium or into the ventricle, depending on the patient’s QSR complex. Some patients may also have dual chamber pacemakers which can sense and pace both the atrium and the ventricle thus manipulating atro-ventricular synchrony. A third group of pacemakers have now emerged called biventricular pace makers with 3 leads – 1 on the atium, the other in the right ventricle and the 3rd in the coronary sinus, which paces the left ventricle so that synchrony can be maintained between the right and left ventricle in patients who have a wide QPS complex (more than 120 – 140 ms) so that there’s an improvement in synchronization and contractility.
ICDs Along with permanent pacing, another device that is inserted by the same route is the Implantable Cardioverter Defibrilator (ICD), this is done in patients who have episodes of ventricular tachycardia or fibrillation and have sometimes been revived from a sudden episode of cardiac death. If this is combined with a biventricular pacemaker in the same device, then it is called a combo device.