Two Cases of an Implantation of a Permanent Pacemaker Using a Transaxillary Incision

In surgeries that require the implantation of a pacemaker, the endocardial pacemaker leads are positioned in the cardiac chambers transvenously through a subclavian approach or cephalic vein cutdown in patients that do not need or have intracardiac shunts or tricuspid prosthetic valves.1), 2) An axillary venous approach for lead placement, which is guided by venography or ultrasonography, is widely used to minimize the risk of lead fracture.3), 4)

In addition to complications related to the implantation of the pacemaker (dislodgement, fracture and infection of leads,)5-7) this type of surgery can also lead to scarring of the pectoral area, which is a serious cosmetic problem particularly in young women. In this study, we report on the implantation of a permanent pacemaker using a transaxillary incision in two young women with symptomatic bradycardia.

In surgeries that require the implantation of a pacemaker, endocardial pacing leads are inserted into the cardiac chambers though subclavian puncture or by cutdown of the cephalic vein.1), 2) Cardiologists typically prefer subclavian puncture to surgical cutdown of the cephalic vein because the approach is easy and advanced surgical skills are not required. An axillary venous approach that is guided by venography or ultransonography is widely used3), 4) because the subclavian venous approach carries the risk of lead conductor and insulation fracture.5), 6) Leads are very rarely implanted through the femoral vein or iliac vein.8), 9)

Implantation of a permanent pacemaker is done mainly in the elderly, but in rare cases it is required in young patients with complete congenital AV blockage and familial sick sinus syndrome.10), 11) Implantable cardioverter defibrillators (ICDs) are mostly implanted in elderly patients with prior myocardial infarction or ischemic heart disease in western countries,12) but young adults with Brugada syndrome comprise a significant proportion of the ICD treatment group in Korea.13)

As a result of the surgical scarring, physicians should pay attention to the cosmetic concerns of young women undergoing implantation of a cardiac rhythm device. Shefer recently reported on 17 cases where retropectoral transaxillary permanent pacemakers were transplanted.14) In addition to the surgical approach presented here, inframammary placement of the generator has also been shown to minimize scarring on the upper chest.15), 16) However, the transaxillary approach, which also produces excellent cosmetic results, has an advantage since this technique does not require deep sedation or general anesthesia. In addition, the shorter distance between the venous access site and pocket makes tunneling easier when compared with the inframammary approach. Furthermore, in the transaxillary approach the two most important adjacent structures (the axillary artery and the brachial plexus) can be avoided.14)

In addition to the cosmetic advantage, the placement of the pulse generator under the pectoralis major muscle eliminates the potential risk of skin erosion, particularly in patients with minimal subcutaneous adipose tissue. Separation of the major and minor pectoralis muscle via a transaxillary incision carries a minimal risk of bleeding when compared with the standard subpectoral pocket generation, which is primarily used for large devices or in patients at high risk of skin erosion.17)

In case 1 it was debatable if a pacemaker was required, since she developed paroxysmal high-grade AV blockage during the recovery phase of myocarditis (not during the active phase). However, the risk of future symptomatic AV blockage was assessed as high; therefore, the pacemaker was implanted. Regarding the cause of the AV blockage in case 1, cardiac sarcoidosis should be considered on the grounds that granulomatous cervical lymphadenopathy, pulmonary lesion and AV block18), 19) were observed in this patient. A positive result for Mycobacteria (using polymerase chain reaction), improvement of lymphadenopathy after administration of antituberculosis medication, a negative endocardial biopsy for granuloma, an evolutionary change in the electrocardiogram, and an elevation of cardiac enzymes all support a diagnosis of myocarditis with separate tuberculous lymphadenopathy rather than sarcoidosis involving the heart and lymph nodes.

In this study we have reported on two cases where the permanent implantation of a pacemaker using a ransaxillary incision in young women resulted in minimal scarring. Therefore, the transaxillary percutaneous technique should be considered in young women who do not want a scar on the upper chest or in patients with minimal subcutaneous tissue, which are at a high risk for skin erosion after implantation of a pacemaker or defibrillator.