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Age, size and lead factors alone do not predict venous obstruction in children and young adults with transvenous lead systems
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ABSTRACT SESSION 44: PEDIATRIC/ADULT CONGENITAL HEART DISEASE III: Advances in Device Therapy in Pediatrics and Congenital Heart Disease Friday, May 6, 2005 4:45 p.m.– 6:15 p.m. AB44-1 AGE, SIZE AND LEAD FACTORS ALONE DO NOT PREDICT VENOUS OBSTRUCTION IN CHILDREN AND YOUNG ADULTS WITH TRANSVENOUS LEAD SYSTEMS Yaniv Bar-Cohen, MD, Charles I. Berul, MD, Mark E. Alexander, MD, Elizabeth B. Fortescue, MD, Edward P. Walsh, MD, *John K. Triedman, MD and Frank Cecchin, MD. Children’s Hospital Boston, Boston, MA. Venous occlusion is a recognized complication of transvenous pacing. A lead index [lead cross-sectional area divided by body surface area (BSA) at time of implant] of ⬎6.6 mm2/m2 has been used to predict venous obstruction in children. The aim of this study was to identify the risk factors and incidence of angiographic venous obstruction after transvenous lead implantation in both children and young adults. Contrast venography was obtained in 85 of 90 consecutive pts undergoing repeat pacemaker or ICD procedures from 2002-04 at a single pediatric cardiac center. At initial implant, the median age was 15.0 yrs (3.2 to 48 yrs) and median weight was 49.9 kg (14 to 104 kg) with pts under 3 years of age receiving epicardial systems. Patients were divided into two age groups: 3-12 yrs (n⫽35, including 15 pts ⱕ 7 yrs) and 13 yrs and over (n⫽50, including 34 pts ⱖ 18yrs). After a median interval of 6.5 yrs from the initial transvenous lead system implant, complete venous obstruction was seen in 11 of 85 pts (12.9%) and significant partial obstruction (⬎70% obstruction with collaterals) in another 10 pts (11.8%). No significant differences were seen in the incidence of obstruction between the two age groups [8 of 35 (23%) in the younger group and 13 of 50 (26%) in the older group] although younger patients were significantly more likely to have a maximal lead index of ⬎6.6 mm2/m2 [20 of 35 (57%) versus 16 of 50 (32%), p⫽0.03]. Furthermore, there were no statistically significant differences between obstructed and non-obstructed pts in terms of age, weight, or BSA at implant, change in BSA or wt from initial implant, duration and number of leads, lead index, prior cardiac surgery, ICD versus pacemaker systems, implant side, prior lead extraction, and more than 1 lead implant procedure. In conclusion, transvenous lead systems implanted in children from age 3 to 12 years have a similar incidence of late venous occlusion compared to our older patients as well as previously published occlusion rates for adults. Furthermore, patient age, body size and lead characteristics at implant do not clearly predict subsequent venous occlusion. AB44-2 FIRST EXPERIENCES WITH CATHETER-GUIDED ATRIAL AND VENTRICULAR LUMENLESS PACING LEAD IMPLANTATION IN 28 PEDIATRIC PATIENTS Bert Hansky, MD, Holger Gueldner, Ute Blanz, MD, Mathias Peuster, MD, PhD, Hans Meyer, MD, PhD and Reiner Koerfer, MD, PhD. Heart Center NRW, Bad Oeynhausen, Germany. The SelectSecure lead (Model 3830, Medtronic, Minneapolis, MN) is a lumenless permanent 4.1 Fr lead for endocardial stimulation which will be implanted via deflectable catheter. Electrical performance in adults have been shown to be equivalent to stylet based leads via multicenter trials. Since December 2003, we implanted 47 leads in 28 pts ⬍⫽ 14 years of age
Heart Rhythm, Vol 2, No 5, May Supplement 2005 for RA (n⫽27) and RV (n⫽20) pacing. Leads were implanted transvenously in 25 pts. In 3 pts, atrial approach via thoracotomy was used for endocardial pacing after Fontan procedure with extracardiac conduit (n⫽2), or postop. DDD-implantation in a pt with a body weight of 4,6 kg. Successful transvenous implantation of 42 leads in 25 pts (body weight range: 7.1 kg for single chamber; 9.1 kg for dual chamber) was performed with a mean fluoroscopy time of 4.9 min. (2.0-8.7). Indications include AV-block (congenital n⫽12, postop. n⫽5) or sinus node dysfunction (Fontan with lateral tunnel n⫽6, Mustard procedure n⫽1, Heart transplantation n⫽1). Thoracotomy and atrial access was used in 3 pts (DDD n⫽2; AAI n⫽1) with contraindication for transvenous access. Initial electrical parameters and after ⬎⫽ 3 months are summarized. There were no procedural complications, no observations of venous occlusion or significant rise (⬎1.0 V) in stimulation thresholds (ST) up to 12 months post implant. One reoperation was performed at 6 weeks due to atrial lead dislodgement. Results demonstrate the feasibility and safety of endocardial placement of lumenless 4.1 Fr leads even in post-surgical pediatric pts with reduced risk of venous occlusion. Advantages of the implantation technique included precise placement and visualization of anatomic variations using contrast media application through the guiding catheter. Procedures were efficient with minimal fluoroscopic exposure and good clinical outcome up to 12 months.
AB44-3 EFFECTIVENESS OF EXCIMER LASER-ASSISTED CARDIAC PACING AND ICD LEAD EXTRACTION IN CHILDREN AND YOUNG ADULTS Jeffrey Moak, MD, Vicki Freedenberg, RN, Allison Skeete and Carolyn Ramwell, RN. Children’s National Medical Center, Washington, DC. Despite advances in pacing lead (PL) design, high capture thresholds, changes in electrical sensing and lead fractures continue to be a frequent problem in children (C) and young adults (YA) undergoing transvenous pacing system implantation. The clinician must therefore decide to either abandon the chronic implanted transvenous lead(s) or extract (E) them using newer methods that have evolved over the last decade. Despite its initial promise in terms of simple removal, use of active fixation cardiac pacing leads in children continues to be a challenge with limited success unassisted. We report our experience using an excimer laser-assisted (LA) strategy for removing chronic pacing and ICD leads in 25 C and YA, ranging in age from 9 to 24 years, undergoing 27 LA PL E procedures. Indication for lead removal was fracture (36) or high capture threshold (1). Twelve C had congenital heart disease. Leads had been implanted for 3-111 months prior to E. Thirty-five leads were active fixation and 2 L were passive fixation. In total, 37 leads were E: 14 atrial, 23 ventricular. Thirtyone were PL and 6 were ICD L. LA PL E was completely successful in 33; and partial in 4, residual L components were L tip (2) and ring electrode (2). LA PLE was used to create a channel for new lead placement in 2 C, with complete occlusion of the subclavian and innominate vein. Complications occurred in 2: subclavian vein thrombosis (1) and ventricular perforation (1). Our results show pacing and ICD leads can be extracted using an excimer laser system with a high success rate and few complications in children and young adults. AB44-4 LEFT VENTRICULAR DYSFUNCTION IS A RARE FINDING FOLLOWING LONG TERM PACING FOR CONGENITAL COMPLETE ATRIOVENTRICULAR BLOCK Jeffrey J. Kim, MD, *Arnold L. Fenrich, Jr., MD, *Bryan C. Cannon, MD, *Richard A. Friedman, MD, Gaurav Arora, MD, *Michelene C. Minor, RN, BSN and *Naomi J. Kertesz, MD. Texas Children’s Hospital, Houston, TX.
ABSTRACT SESSION 44: PEDIATRIC/ADULT CONGENITAL HEART DISEASE III: Advances in Device Therapy in Pediatrics and Congenital Heart Disease Friday, May 6, 2005 4:45 p.m.– 6:15 p.m. AB44-1 AGE, SIZE AND LEAD FACTORS ALONE DO NOT PREDICT VENOUS OBSTRUCTION IN CHILDREN AND YOUNG ADULTS WITH TRANSVENOUS LEAD SYSTEMS Yaniv Bar-Cohen, MD, Charles I. Berul, MD, Mark E. Alexander, MD, Elizabeth B. Fortescue, MD, Edward P. Walsh, MD, *John K. Triedman, MD and Frank Cecchin, MD. Children’s Hospital Boston, Boston, MA. Venous occlusion is a recognized complication of transvenous pacing. A lead index [lead cross-sectional area divided by body surface area (BSA) at time of implant] of ⬎6.6 mm2/m2 has been used to predict venous obstruction in children. The aim of this study was to identify the risk factors and incidence of angiographic venous obstruction after transvenous lead implantation in both children and young adults. Contrast venography was obtained in 85 of 90 consecutive pts undergoing repeat pacemaker or ICD procedures from 2002-04 at a single pediatric cardiac center. At initial implant, the median age was 15.0 yrs (3.2 to 48 yrs) and median weight was 49.9 kg (14 to 104 kg) with pts under 3 years of age receiving epicardial systems. Patients were divided into two age groups: 3-12 yrs (n⫽35, including 15 pts ⱕ 7 yrs) and 13 yrs and over (n⫽50, including 34 pts ⱖ 18yrs). After a median interval of 6.5 yrs from the initial transvenous lead system implant, complete venous obstruction was seen in 11 of 85 pts (12.9%) and significant partial obstruction (⬎70% obstruction with collaterals) in another 10 pts (11.8%). No significant differences were seen in the incidence of obstruction between the two age groups [8 of 35 (23%) in the younger group and 13 of 50 (26%) in the older group] although younger patients were significantly more likely to have a maximal lead index of ⬎6.6 mm2/m2 [20 of 35 (57%) versus 16 of 50 (32%), p⫽0.03]. Furthermore, there were no statistically significant differences between obstructed and non-obstructed pts in terms of age, weight, or BSA at implant, change in BSA or wt from initial implant, duration and number of leads, lead index, prior cardiac surgery, ICD versus pacemaker systems, implant side, prior lead extraction, and more than 1 lead implant procedure. In conclusion, transvenous lead systems implanted in children from age 3 to 12 years have a similar incidence of late venous occlusion compared to our older patients as well as previously published occlusion rates for adults. Furthermore, patient age, body size and lead characteristics at implant do not clearly predict subsequent venous occlusion. AB44-2 FIRST EXPERIENCES WITH CATHETER-GUIDED ATRIAL AND VENTRICULAR LUMENLESS PACING LEAD IMPLANTATION IN 28 PEDIATRIC PATIENTS Bert Hansky, MD, Holger Gueldner, Ute Blanz, MD, Mathias Peuster, MD, PhD, Hans Meyer, MD, PhD and Reiner Koerfer, MD, PhD. Heart Center NRW, Bad Oeynhausen, Germany. The SelectSecure lead (Model 3830, Medtronic, Minneapolis, MN) is a lumenless permanent 4.1 Fr lead for endocardial stimulation which will be implanted via deflectable catheter. Electrical performance in adults have been shown to be equivalent to stylet based leads via multicenter trials. Since December 2003, we implanted 47 leads in 28 pts ⬍⫽ 14 years of age
Heart Rhythm, Vol 2, No 5, May Supplement 2005 for RA (n⫽27) and RV (n⫽20) pacing. Leads were implanted transvenously in 25 pts. In 3 pts, atrial approach via thoracotomy was used for endocardial pacing after Fontan procedure with extracardiac conduit (n⫽2), or postop. DDD-implantation in a pt with a body weight of 4,6 kg. Successful transvenous implantation of 42 leads in 25 pts (body weight range: 7.1 kg for single chamber; 9.1 kg for dual chamber) was performed with a mean fluoroscopy time of 4.9 min. (2.0-8.7). Indications include AV-block (congenital n⫽12, postop. n⫽5) or sinus node dysfunction (Fontan with lateral tunnel n⫽6, Mustard procedure n⫽1, Heart transplantation n⫽1). Thoracotomy and atrial access was used in 3 pts (DDD n⫽2; AAI n⫽1) with contraindication for transvenous access. Initial electrical parameters and after ⬎⫽ 3 months are summarized. There were no procedural complications, no observations of venous occlusion or significant rise (⬎1.0 V) in stimulation thresholds (ST) up to 12 months post implant. One reoperation was performed at 6 weeks due to atrial lead dislodgement. Results demonstrate the feasibility and safety of endocardial placement of lumenless 4.1 Fr leads even in post-surgical pediatric pts with reduced risk of venous occlusion. Advantages of the implantation technique included precise placement and visualization of anatomic variations using contrast media application through the guiding catheter. Procedures were efficient with minimal fluoroscopic exposure and good clinical outcome up to 12 months.
AB44-3 EFFECTIVENESS OF EXCIMER LASER-ASSISTED CARDIAC PACING AND ICD LEAD EXTRACTION IN CHILDREN AND YOUNG ADULTS Jeffrey Moak, MD, Vicki Freedenberg, RN, Allison Skeete and Carolyn Ramwell, RN. Children’s National Medical Center, Washington, DC. Despite advances in pacing lead (PL) design, high capture thresholds, changes in electrical sensing and lead fractures continue to be a frequent problem in children (C) and young adults (YA) undergoing transvenous pacing system implantation. The clinician must therefore decide to either abandon the chronic implanted transvenous lead(s) or extract (E) them using newer methods that have evolved over the last decade. Despite its initial promise in terms of simple removal, use of active fixation cardiac pacing leads in children continues to be a challenge with limited success unassisted. We report our experience using an excimer laser-assisted (LA) strategy for removing chronic pacing and ICD leads in 25 C and YA, ranging in age from 9 to 24 years, undergoing 27 LA PL E procedures. Indication for lead removal was fracture (36) or high capture threshold (1). Twelve C had congenital heart disease. Leads had been implanted for 3-111 months prior to E. Thirty-five leads were active fixation and 2 L were passive fixation. In total, 37 leads were E: 14 atrial, 23 ventricular. Thirtyone were PL and 6 were ICD L. LA PL E was completely successful in 33; and partial in 4, residual L components were L tip (2) and ring electrode (2). LA PLE was used to create a channel for new lead placement in 2 C, with complete occlusion of the subclavian and innominate vein. Complications occurred in 2: subclavian vein thrombosis (1) and ventricular perforation (1). Our results show pacing and ICD leads can be extracted using an excimer laser system with a high success rate and few complications in children and young adults. AB44-4 LEFT VENTRICULAR DYSFUNCTION IS A RARE FINDING FOLLOWING LONG TERM PACING FOR CONGENITAL COMPLETE ATRIOVENTRICULAR BLOCK Jeffrey J. Kim, MD, *Arnold L. Fenrich, Jr., MD, *Bryan C. Cannon, MD, *Richard A. Friedman, MD, Gaurav Arora, MD, *Michelene C. Minor, RN, BSN and *Naomi J. Kertesz, MD. Texas Children’s Hospital, Houston, TX.