Endocardial (Transvenous) Approach
This is the most widely used approach. In this approach a small incision is made over the chest, under local anesthesia and sedation. The lead of the pacemaker is then inserted through the incision into a cardiac vein, guided by intra-operative fluoroscopy, and the lead is lodged into the heart tissue. The leads are then tested by transmitting a small amount of energy to contract the heart. After having successfully tested the leads, the other end is connected to the pacemaker. In this approach, the pacemaker is placed in a small pocket under the skin of the chest.
Epicardial Approach
This is a less common approach. It is used more often in children and patients undergoing heart surgery at the same time. This procedure is performed under general anesthesia. The lead of the pacemaker is attached to the epicardium, the outer layer of the wall of the heart. Once the leads are tested, the other end is connected to the pacemaker that is placed in a pocket created under the skin of the abdomen. This approach takes a longer operative and recovery time than the endocardial approach. This can be significantly reduced with the use of minimally invasive techniques.
Irrespective of the approach, the final adjustments of the pacemaker are made by the doctor after the pacemaker implantation by using an external device. The settings of the pacemaker depend on the individual requirement of electrical energy to stimulate normal heart rhythm.
Your cardiac surgeon will determine the best approach depending on your age and other associated conditions.