Is a post pacemaker implantation routine chest x ray necessary?

Abstract

Introduction: The routine use of post pacemaker implantation chest X ray (CXR) to rule out pneumothorax and check lead position is a practice according to established protocols. Life time exposure to medical radiation is increasing. As the dose of radiation is cumulative it is vital to reduce radiation exposure. Methods: A retrospective study at the Aga Khan University hospital to assess the need for a post implantation CXR. All patients undergoing pacemaker implantation between October 2009 and December 2012 were included. The center had three implanting physicians. Results:A total number of 317 cases. Sixty seven percent were males, the mean age of the dual chamber (DC) group was 68.2 years, age range (22 to 91 years), and while for the single chamber pacemaker (SC) it was 70 years with age range 24 to 93 years. Except for one patient who had cephalic cut down, the rest underwent subclavian vein (SCV) puncture. The subclavian vein puncture was done under fluoroscopy. Pneumothorax occurred in 2 cases (0.63%). Both cases were during DC pacemaker implantation. Both cases required chest tube insertion. Acute lead displacement occurred in 5 cases (1.57%). The lead displacement occurred after the post procedure CXR as per protocol. These were all picked up by symptoms and pacemaker interrogation, where failure to capture and under-sensing was noted. Both pneumothorax patients had structural chest and lung abnormality; one had kyphoscoliosis, while the other had severe left apical lung fibrosis (pulmonary TB). Conclusion: Pneumothorax occurred in 0.63% of the cases which could be predicted pre procedure and the lead displacement occurred later and was picked up through device interrogation and symptoms. In the normal SCV puncture provided the pre-implantation CXR was normal and post implantation physical examination was normal a CXR did not add to the management. Keywords: PPM, complication, pneumothorax, lead displacemen