Cardiovascular implantable electrical device (CIED) is a generalized term for pacemakers,
implantable cardiac devices (ICDs) and cardiac resynchronization therapy (CRT) devices.
CRT is a modality of cardiac pacing that provides simultaneous pacing of left ventricle
(LV) and right ventricle (RV) as biventricular (BiV) pacing (CRT-pacemaker or CRT-P), or
by a combined CRT-implantable-defibrillator (CRT-D). The indication for pacemaker
implantation in a patient is abnormal cardiac electrical conduction such as sinus node
dysfunction or high-grade atrioventricular block. CRT is indicated for patients with
symptomatic heart failure with left bundle branch block. Patients undergoing CIEDs often
have multiple other associated comorbidities such as pulmonary disease, chronic kidney
disease etc. which places them at a high-risk for undergoing these procedures.
Every year, more than 500,000 CIEDs are implanted in the United States alone. These
procedures are being done with increasing frequency in patients with arrhythmias, heart
failure and other risk factors for sudden cardiac death. Opioid prescription usage and
persistent use of opioids after CIED procedures remains very high. In the context of
current opioid crisis, there is a growing need to find alternatives to optimize pain and
limit opioid usage in the patient population.
The current standard practice for CIED placement is either under monitored anesthesia
care (MAC) or general anesthesia. MAC is sedation and is usually performed using
benzodiazepines, opioids, and propofol. Deleterious effects of opioids during sedation
include respiratory or hemodynamic compromise, particularly in this high-risk patient
population with low reserve. General anesthesia is invasive requiring endotracheal
intubation and positive pressure ventilation, which can also compromise cardiorespiratory
function. Finally, some patients with obesity or obstructive sleep apnea may have low
tolerance to sedation and opioid use in procedures involving tunneling of leads or deeper
chest wall tissue dissection. Despite procedural sedation or general anesthesia, patients
generally continue to require pain medications postoperatively due to residual pain from
the procedure.
Nerve blocks involve injection of local anesthetic around peripheral nerves or their
branches to interrupt pain and other sensory signals thus alleviating pain. Pectoralis or
Pecs block is one such nerve block and has recently been effectively in increasing
evidence for various surgeries and procedures on chest wall. Few case reports in adult
population undergoing pacemaker, ICD and CRT placement also emphasize the utility of
these blocks especially in patients who are critically ill. Preliminary studies have
shown lower sedation requirements and higher patient and proceduralist satisfaction with
use of PEC block in these patients.
Moreover, there is no large study has evaluated the utility of PECs block in this patient
population undergoing CIED insertion and there remains a need to investigate their
utility in a systematic study.
There are two components to a Pecs block: Pecs I block that targets the lateral and
medial pectoral nerves, suppliying both pectoral muscles (major and minor, and Pecs II
block that targets the anterior and lateral division of the thoracic intercostal nerves
T2-T6, the long thoracic nerve (C5-C7) which supplies the serratus anterior muscle and
the thoracodorsal nerve (C6-C8) which innervates the latissimus dorsi muscle. Thus,
combination of both Pecs I and II blocks can provide a widespread analgesic coverage and
has been previously studied for analgesia for breast surgeries and also in thoracic
trauma. It is a promising option considering its efficacy and ease of administration and
may prove to be a useful analgesic technique in patients undergoing CIED insertion or
replacement. The block is devoid of the systemic adverse events associated with opioids
and hemodynamic complications associated with general anesthesia. It is a relatively
superficial block and is therefore safe even on patient on antiplatelet therapy. It could
prove useful in reducing intra-procedure analgesic requirement in the acute setting of
postoperative pain as well as preventing chronic pain and has the potential to become the
standard of care for analgesia in CIED procedures.
