8 * Submammary device implantation: long-term results

Abstract

Conventional pacemaker and ICD implantation in women can be disfiguring with adverse psychological and social effects. The submammary position, between breast capsule and pre-pectoral fascia, allows devices to be hidden with good tissue cover. Implantation is by a small infraclavicular incision for vein access and lead fixation; a second incision lateral or inferior to the breast gives acces to the submammary plane for creation of the pocket. The lead(s) are tunnelled to the pocket and the device implanted in a central retromammary position. The lower incision is closed in 4 layers and the upper in 2. Details of the technique are discussed. The results of 131 consecutive single-operator procedures on 74 women, age 15–79 (mean 42) years between 1986 and 2013 are reported. The devices were pacemakers (118), ICDs (11) and Internal loop recorders (2). The initial procedures were primary implants (70) and revision or replacement of existing systems (5). Further procedures were generator replacement (35), lead revision, replacement or addition (11), pocket revision (6), system replacement (2) and system removal (2). Early complications were small pneumothorax (2) and lead displacement (5). There was no loss of sensation in the breast and no persistant discomfort or limitation of movement except in some cases of device migration. Average follow-up from initial procedure is over 12 years (3–327 months, mean 145). Late complications were device migration (7), skin erosion and infection (3) and lead failure (3). Further procedures were undertaken by other operators: device replacement (4) lead revision (1) and upgrade to ICD (1). Four patients have died from non-device-related causes. Present follow-up status is unknown for 4 patients. Submammary device implantation is a safe and successful procedure. Developments in technique over the study period have reduced complications especially lead displacement and device migration.