Injuries associated with percutaneous placement of transthoracic pacemakers.

Injuries associated with the percutaneous placement of transthoracic pacemakers are poorly documented. We prospectively sought to determine any injuries associated with various placement routes. Six different approaches were used in each of 20 adult patients examined at autopsy. Three parasternal approaches utilized the fifth intercostal space (5ICS). One pacing wire was inserted immediately to the left of the sternum along the parasternal line (5ICS-PS), one pacing wire was inserted 4 cm to the left of the midsternal line (5ICS-4), and the third wire was inserted 6 cm from the midsternal line (5ICS-6). All parasternal needle insertions were directed medially, dorsally, and cephalad toward the right second costochondral junction at an angle of 30 degrees to the skin. Three subxiphoid approaches were inserted through the left xyphocostal notch at an angle of 30 degrees to the skin. One pacing wire was directed toward the right shoulder, one toward the sternal notch, and one toward the left shoulder (SXLS). Injuries were assessed by autopsy, postmortem coronary angiography, and stereoscopic radiography. The 5ICS-PS approach resulted in fewer injuries when compared to all other approaches. Because previous work has demonstrated that the 5ICS-PS, 5ICS-6, and SXLS approaches are more accurate than the other approaches for transthoracic pacemaker insertion, the 5ICS-PS represents an approach that combines reasonable accuracy with the least likelihood for injury in the placement of percutaneous transthoracic pacing wires.