78 Who should have VVI pacemakers and who
should have dual chamber pacemakers? What are
the risks of pacemaker insertion?
Alistair Slade
Many pacing enthusiasts argue that there are very few indications
for VVI pacing, perhaps confining its role to the very elderly with
established atrial fibrillation and documented pauses. Dual
chamber pacing (or more accurately physiological pacing which
may include single chamber atrial devices) is the preferred mode
in most common indications for pacemaker implantation.
The British Pacing group published its recommendations in
1991.^1 These have led to widespread if gradual change in British
pacing practice. Physiological pacemakers can be recommended
in sinus node disease on the basis of many retrospective studies
and one prospective study.^2 Ongoing prospective studies will
clarify the true role of physiological pacing in the elderly with AV
conduction disease. The British guidelines are similar to those in
the United States. A more comprehensive guide to pacemaker
implantation is given by the ACC/AHA joint guidelines which
supply the level of evidence for each recommendation and a
comprehensive reference list.^3
Pacemaker implantation is a remarkably safe procedure.
Mortality is minimal and occurs due to unrecognised
pneumothorax, pericardial tamponade or great vessel trauma.
Complications at implant are those of subclavian puncture,
particularly pneumothorax, although these can be avoided if the
cephalic approach is used. There is some long term evidence that
the cephalic approach may avoid chronic lead failure in
polyurethane leads due to subclavian crush injury. Haematoma
requiring re-operation should occur in less than 1%. Infection
leading to explant similarly occurs in approximately 1%. Acute
lead displacement should be less than 1% for ventricular leads
and 1–2% for atrial leads.
RReeffeerreenncceess
1 Clark M, Sutton R, Ward DE et al. Recommendations for pacemaker
prescription for symptomatic bradycardia. Report of a working party
of the British Pacing and Electrophysiology Group. Br Heart J
1991; 6666 : 185–91.