Who should have VVI pacemakers and who should have dual chamber pacemakers? What are the risks of pacemaker insertion?

Many pacing enthusiasts argue that there are very few indications for VVI pacing, perhaps confining its role to the very elderly with established atrial fibrillation and documented pauses. Dual chamber pacing (or more accurately physiological pacing which may include single chamber atrial devices) is the preferred mode in most common indications for pacemaker implantation. The British Pacing group published its recommendations in 1991.1 These have led to widespread if gradual change in British pacing practice. Physiological pacemakers can be recommended in sinus node disease on the basis of many retrospective studies and one prospective study.2 Ongoing prospective studies will clarify the true role of physiological pacing in the elderly with AV conduction disease. The British guidelines are similar to those in the United States. A more comprehensive guide to pacemaker implantation is given by the ACC/AHA joint guidelines which supply the level of evidence for each ecommendation and a comprehensive reference list.

Pacemaker implantation is a remarkably safe procedure. Mortality is minimal and occurs due to unrecognised pneumothorax, pericardial tamponade or great vessel trauma. Complications at implant are those of subclavian puncture, particularly pneumothorax, although these can be avoided if the cephalic approach is used. There is some long term evidence that the cephalic approach may avoid chronic lead failure in polyurethane leads due to subclavian crush injury. Haematoma requiring re-operation should occur in less than 1%. Infection leading to explant similarly occurs in approximately 1%. Acute lead displacement should be less than 1% for ventricular leads and 1–2% for atrial leads.