Pacemaker-ICD Implantation (Permanent)

Endocardial (transvenous) approach 

• Access site is through an incision in the chest.
• Insert a guide catheter into the vein (vena cava) and then put the guidewire (J-wire) through the guide catheter into the vein.
• Remove the guide catheter out of the vein, leaving behind the J-wire still inside the vein.
• Insert the introducer sheath through the J-wire into the vein – if needed suture it in place. Introducer sheath has a port for administering medicine such as blood-thinners.
• Pull out the guide wire (and its dilator) out of the introducer sheath.
• Guide the electrode wire into the introducer sheath and into the vein, using real-time fluoroscopic images, all the way to the heart. The electrode wire is usually 30-50 cm depending on the patient. 
• Attach an electrical port helper to the part of the electrode wire outside the vein. The branch of the helper labeled as ‘distal’ is then connected to the V2 chest lead on the EKG machine.

• Descend the electrode wire down the vena cava into the right atrium. EKG will guide the position of the wire:

• The two connections of the electrodes are then connected to a pacemaker generator that is implanted under the skin under the left clavicle.

Epicardial (surgical) approach

• In this approach, the patient is administered general anesthesia.
• An incision is made through the chest to the heart.
• The electrode is attached directly on the heart muscle through the incision.
• The other end of the electrode wire is connected to a pacemaker-ICD generator  which is implanted in a skin pocket under the abdomen.
• This procedure is mainly done for children.