Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 51, Num. 2, 2005, pp. 96-97

Journal of Postgraduate Medicine, Vol. 51, No. 2, April-June, 2005, pp. 96-97

Expert's Comments

Chest radiography after permanent cardiac pacemaker placement

Hunter T.B.

Department of Radiology, University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724-5067

Correspondence Address: Department of Radiology, University of Arizona College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724-5067, tbh@3towers.com

Code Number: jp05037

The current issue of the Journal of Postgraduate Medicine contains a thought-provoking article "Routine chest radiography after permanent pacemaker implantation: Is it necessary?"[1] The authors performed a retrospective analysis of pacemaker placement and post-procedure chest radiographs for 126 consecutive patients after standard placement of either a first endocardial pacemaker implantation or insertion of at least one new cardiac pacemaker lead. They found the vast majority of their patients had satisfactory lead placement as evaluated by the chest radiographs, and those whose leads were in a marginal position had satisfactory pacemaker functioning. Only one iatrogenic pneumothorax occurred in their patients. The authors concluded that in this series of patients the need for patient intervention was governed by malfunction of the pacemaker system, and it was not influenced by the findings on routine and subsequent radiography. According to this report, "Immediate radiography may be reserved for those patients with at least moderate probability of iatrogenic pneumothorax."

The conclusion from this report is the opposite of the current practice at my home institutions in Tucson, Arizona, USA, where chest radiographs are obtained after every cardiac pacemaker placement no matter the type or placement situation. It also is somewhat counter to my anecdotal experience of seeing 2-4 pneumothoraces per month in a population of patients receiving pacemakers from a busy cardiac specialty hospital and from patients receiving pacemakers from an active cardiology service at a university medical centre. The patients I am familiar with are a complex mix of those requiring elective pacemaker placement and those receiving a pacemaker in an emergency situation. The patients reported by the authors were admitted for elective day-case first endocardial permanent pacemaker insertion or revision of their system including new lead insertion.

The procedures were performed in a district general hospital in the United Kingdom. The interval between when the pacemaker was inserted and the chest radiograph was obtained was not specified in this report. It is well known that pneumothoraces resulting from lung biopsies or thoracentesis may be delayed in their presentations from 1-24 hours, and we routinely obtain post-procedural and 4-hour delayed chest radiographs in these situations. It has been my anecdotal experience that patient symptoms are an unreliable predictor for the presence of a pneumothorax. Of course, in these cases, there has been a direct violation of the pleural space.

The authors′ survey of the literature and my limited literature survey show that the post-procedural complication rate for elective placement of a cardiac pacemaker is low, and it is best determined by patient evaluation and by pacemaker monitoring. Pneumothoraces requiring treatment rather than watchful waiting occur less than 1% of the time. The question then remains that have the authors in their own practice stopped obtaining chest radiographs in asymptomatic patients after routine pacemaker placement? In other words, do they practice what they preach? The answer seems to be yes. According to the authors, "we perform post-procedural chest radiographs only in patients with moderate to high likelihood of pneumothorax." They are also performing a prospective study to further look at this very question.

In our practice here we will continue to obtain post-pacemaker placement chest radiographs. Why? Because our patient population is different, and it probably consists of more difficult and emergent pacemaker placements. Also, we live in a land awash in malpractice litigation. Alas, the facts and the science often don′t often matter in this situation, but that is another story.

REFERENCES

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