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 Table of Contents  
Year : 2021  |  Volume : 2  |  Issue : 2  |  Page : 166-168

Submuscular placement of pacemaker: A new method

1 Department of Burn and Plastic Surgery, AIIMS, Rishikesh, Uttarakhand, India
2 Department of Cardiology, AIIMS, Rishikesh, Uttarakhand, India

Date of Submission11-Mar-2020
Date of Decision26-Jul-2021
Date of Acceptance11-Aug-2021
Date of Web Publication30-Aug-2021

Correspondence Address:
Dr. Vishal Mago
Additional Professor and HOD, Department of Burn and Plastic Surgery, AIIMS Rishikesh, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JME.JME_30_21

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How to cite this article:
Mago V, Manohar N, Duggal B. Submuscular placement of pacemaker: A new method. J Med Evid 2021;2:166-8

How to cite this URL:
Mago V, Manohar N, Duggal B. Submuscular placement of pacemaker: A new method. J Med Evid [serial online] 2021 [cited 2022 Aug 10];2:166-8. Available from: http://www.journaljme.org/text.asp?2021/2/2/166/324961

  Introduction Top

Pacemaker implants have been used in the department of cardiology for a long time. It is fraught with complications such as exposure and migration of implants.

These implants are placed in subclavian area and consist of a pulse generator and active leads are placed in subclavian vein. Arrhythmic disorders are very common in this part of India where a lot of pacemakers are implanted in aged population. Placement is based on the mental status, cosmetic concerns and functional role of the pacemaker. Cosmetic concerns are more in the younger population, especially women who are conscious about their appearance after their placement. Young patients are at more risk of mechanical complications due to erosion or infection. Anxiety of wearing a bathing suit in women or sexual encounters can be a hindrance.

Implants placed in subcutaneous pockets in thin patients or the elderly can be easily displaced or get exposed due to compromised blood supply and thinned-out skin. Gangrene of overlying flaps can also occur due to the larger size of implants.

The authors have devised a new technique to overcome these complications by placing the implant by splitting the pectoralis muscle fibres and pocket creation and achieving a cosmetic scar.

  Methods Top

This case series has been performed in five patients in the Department of Cardiology in collaboration with Department of Burns and Plastic surgery in a series of pacemaker implants in AIIMS Rishikesh. Local anaesthesia is infiltrated around the marked incision. An infraclavicular incision is given parallel to the implanted lead of pacemaker implant in a vertical direction [Figure 1]. Skin along with subcutaneous tissue is cut by a 15 number blade to reach the glistening fascia over the pectoralis major muscle.
Figure 1: Submuscular placement of pacemaker with less prominence

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This fascia is cut with scissors and muscle fibres are split in a vertical direction and a submuscular pocket is created with blunt and sharp dissection.

The cavity is irrigated with saline and any bleeders are cauterised. The pacemaker is easily inserted into this pocket and leads are connected. Muscle fibres are approximated with Vicryl 2-0 suture and skin is closed with Ethilon 3-0 suture. The leads are tunnelled through the muscle for better securement and proximity to the implant [Figure 2].
Figure 2: Post-operative result

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Sutures are removed after 7 days. A good aesthetic and cosmetic scar result is achieved.

  Results Top

Good results have been achieved with this anterior approach technique with its simplicity, ease of application and robustness of muscle flap. Less chances of infection due to extrusion are seen within this muscle pocket. No migration of implant is seen. No infection was seen with use of this method. Since muscle is not cut in this procedure, there is no problem with post-operative mobility of shoulder. Minimal pocket fullness is displayed.

Criteria for a good result can be ascertained by:

  1. Placement of expander in a submuscular plane versus subcutaneous placement
  2. Lead placement is easy and does not interfere with the implant
  3. Chances of bleeding are less in a subfascial plane
  4. The surgeon is comfortable performing this procedure as the slippage is less
  5. Infection is abolished on account of vascularity of the muscle and a stable pocket is formed. Moreover, splitting of the muscle is an added advantage.

The follow-up was done in all the patients till the patient got his stitches removed with no problem or complication afterwards. A novice cardiac doctor or surgeon can perform this procedure with ease and comfort. Elderly population will benefit with this procedure on account of submuscular placement, less chances of visibility and easy aftercare. No lead breakage was seen in any of the cases. Thin or obese patient does not affect the outcome of this study.

The advantages of new technique over classical technique are summarised in [Table 1].
Table 1: Advantages of new technique over classical technique

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  Discussion Top

Previous technique of infraclavicular placement of implant was over the surface of pectoralis major muscle and leads were connected. A deltopectoral groove incision was advocated by Roelke et al. by direct axillary puncture and a small pocket was created over the muscle.[1]

Shefer described the retropectoral transaxillary technique whereby a pocket was created between the two muscles. Two electrodes were inserted and secured to pectoral fascia.[2] Noro et al. used the left axilla displacement technique in 40 cases with two cases of lead dislodgement.[3]

The authors have indicated pacemaker implants for the extremely thin patient at risk for erosion and the young patient concerned with body image.[4]

A subcutaneous small electrode patch, array, or single coil has been added as a safety measure for the survival of implanted device system.[5]

Unsightly scars, device bulges and protrusion of the pacemaker implants have caused concern in emerging era.

The technique of axillary implantation is suited in children with congenital heart disease due to its small size and less chance of myocardial damage.[6] The pulse generator was placed in subxiphoid epigastric muscular pocket in neonates with a complete AV block.[7]

Kim et al. found the implant to be less visible and palpable with subpectoral placement as compared to prepectoral implantation. Subclavian scar was more visible in prepectoral pocket.[8] The use of submuscular pocket in women does not alter breast symmetry or volume.[9] Caudal displacement was seen in only two cases.

Toia et al. reported exposure of five devices in their study. One infected pacemaker was replaced. Complete capsulectomy and irrigation with n acetyl cysteine was performed. All five devices were placed in a subpectoral pocket.[9]

The authors reported 11 primary exposures of venous ports, 10were placed in a subcutaneous pocket: 4 were covered with a random flap, 2 with a propeller flap, and 4 with a perforator-based flap.Immediate replacement was done for gross infection.[10]

This new technique of device implantation with muscle splitting and pocket creation is easy to execute, with less chances of migration or extrusion and low threshold of infection. There is less protrusion or display of implant in comparison to subcutaneous placement. Functional mobility is not hampered. This approach can be used in revision cases or migration of implants. Age and skin condition does not preclude use of this approach.

This new procedure can be executed with ease with less assistance as splitting of muscle is an easy technique to master. The chances of infection are abolished due to submuscular placement. Early mobilisation of shoulder and upper limb can be achieved. The lead breakerage is less due to muscle cover as compared to classical technique. Obese and thin patients can benefit with this new technique on account of submuscular pocket with less prominence. The thin patients have a high chance of skin necrosis and lead breakerage in classical technique.

Utility of this technique in elderly population is warranted as skin is thin and pliable so submuscular placement will prevent extrusion, cosmetic scar and exhibit less visibility with early mobilisation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Roelke M, Jackson G, Harthorne JW. Submammary pacemaker implantation: A unique tunneling technique. Pacing Clin Electrophysiol 1994;17:1793-6.  Back to cited text no. 1
Shefer A, Lewis SB, Gang ES. The retropectoral axillary permanent pacemaker: Description of a technique for percutaneous implantation of an invisible device. Pacing Clin Electrophysiol 1996;16:1646-51.  Back to cited text no. 2
Noro M, Zhu X, Takagi T, Sahara N, Narabayashi Y, Hashimoto H, et al. Left axillary pacemaker generator implantation with a direct puncture of the left axillary vein. Pacing Clin Electrophysiol 2015;38:35-41.  Back to cited text no. 3
Belott PH. Cosmetic aspects of device implantation. Heart Rhythm 2019;16:308-11.  Back to cited text no. 4
Yokoyama Y. Implantation site does matter for defibrillation threshold. Circ J 2016;80:816-7.  Back to cited text no. 5
Suzuki T, Sumitomo N, Yoshimoto J, Miyazaki A, Hinokiyama K, Ushinohama H, et al. Current trends in use of implantable cardioverter defibrillators and cardiac resynchronization therapy with a pacemaker or defibrillator in Japanese pediatric patients: Results from a nationwide questionnaire survey. Circ J 2014;78:1710-6.  Back to cited text no. 6
Costa R, Silva KR, Martinelli Filho M, Carrillo R. Minimally invasive epicardial pacemaker implantation in neonates with congenital heart block. Arq Bras Cardiol 2017;109:331-9.  Back to cited text no. 7
Kim SH, Seo BF, Choi Y, Kim JY, Oh YS. Subpectoral implantation of cardiovascular implantable electronic device: A reasonable alternative for the conventional prepectoral approach. World J Plast Surg 2019;8:163-70.  Back to cited text no. 8
Persichetti P, Brunetti B, Cagli B, Manzo MJ, Pignalberi C, Ansalone G. Aesthetic subpectoral placement of implantable cardioverter defibrillators. Ann Plast Surg 2014;72:188-92.  Back to cited text no. 9
Toia F, D'Arpa S, Cordova A, Moschella F. Exposed subcutaneous implantable devices: An operative protocol for management and salvage. Plast Reconstr Surg Glob Open 2015;3:e343.  Back to cited text no. 10


  [Figure 1], [Figure 2]

  [Table 1]


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