An emergency method of handling broken pacemaker wires in children

An Emergency

Method

Pacemaker R. KAHN,

DONALD

A

mal

dling

STERN.: M.D., JOAN SIGMANN, M.D. and HERBERT

M.D., AARON

delay

used the

and

in any

occurs

trauma.

such

bringing

an.d

form

an

the

for

method

its

the

can

in

be

from

the

sub-

In our experience

majority.

Moreover, in

the

to a subcutaneous

can be adapted

by

heart

SLOAN, M.D.

Michigan

missures of the pulmonary valve were incised. A ‘Teflon’“‘ patch was sutured in the ventricular septal defect. During this procedure a complete heart block occurred. Because the block persisted after normal circulation was restored, a pacemaker wire was placed in the right ventricle and attached to a transistorized external pacemaker (Medtronic) for maintenance during the postoperative period. The patient did well except for the persistent heart block. When the pacemaker wire was removed, her pulse rate remained between 55 and 60. She was discharged in March on a drug regimen including 10

mini-

in .the wire

insertion

electrode

the wires

Arbor,

han-

with

break

battery.

extra

this method

This

where

placed

cases

wires

the sites of its emergence

and

cutarreously

devised

pacemaker

case

between

chest

placing

has been

broken

Broken

Wires in Children* Ann

SIMPLE method

of Handling

an.d

position,

to any type of failure

in the pacemaker. Permanent with

complete

a heart

rate

the p1acemen.t usual

intracardiac juries they

of

injury

occurred

constitute

emergency

bundle Even.

rarely

a serious following

approach

in children for

pacemaker.’

condition. the

the installation The

maker.

to

surgery.

have

requiring

this

block

50 is an indication

of an artificial

cause

operative

heart

below

in

children

of

His

though in. our

is

during

these

in-

experience,

complication

usually

of a permanent case is illustrative

to pacemaker

The

paceof this

failure.

CASE HISTORY The patient was a 7 year old girl who was first admitted to the University of Michigan Hospital in October 1961, when she was 4 years old. The clinical and hemodynamic findings were those of infundibular and pulmonic valve stenosis and a high ventricular septal defect with a left to right shunt. A diagnosis of tetralogy of Fallot was made. The patient was scheduled for a primary open-heart repair of the lesion in February 1962. At operation, performed in conjunction with extracorporeal circulation, a moderate infundibular and pulmonary valve stenosis was found. A high ventricular defect, measuring about 1.5 cm. in greatest diameter, was found at the site usually seen in tetralogy of Fallot. Also a tiny patent ductus arteriosus was noted. This ductus was ligated, the hypertrophied infundibulum was resected, and the com* From the Departments

of Surgery

FIG. 1. A roentgenogram taken with patient bending over reveals a marked curvature of the wires between the costal margin and the subcutaneously placed battery.

and Pediatrics, 404

University

Medical

Center,

Ann Arbor, Mich.

THE AMERICAN JOURNAL OF CARDIOLOGY

405

Broken Pacemaker Wires

External /-? battery +

FIG. 3. A new internal battery was left in the chest cavity. Extra cardiac electrode wires were buried subcutaneously. FIG. 2. The wires are brought out through a 1 inch incision and connected to a transistorized external unit. mg. of isoproterenol hyckochloride three times a day and 25 mg. of ephedrine before bedtime. In May the patient was again admitted to the University Hospital because of an acute episode of apnea and unconsciousness which had occurred three hours before. She recovered and again was discharged on the same drug regimen, but during the next few months her heart rate fell from 55 to 40 and her general condition grew worse. In December she was readmitted for the surgical placement of an internal pacemaker (General Electric), the battery being placed subcutaneously in the left side of the abdomen. The pacemaker established a regular cardiac rate of 80. Thereafter the child was quite well and her appetite increased. She was again able to resume normal activity and gain weight. Five months later on a routine clinic visit there was concern because a roentgenogram taken while she was bending over revealed a marked curvature of the wires between the costal margin and the subcutaneously placed battery (Fig. 1). Two weeks later a sudden emergency caused her readmission to the hospital, in critical condition. Her heart rate was 40; she repeatedly lapsed into unconsciousness. Severe bradycardia and a convulsive state developed, and the patient became semicomatose, responding poorly to isoproterenol hydrochloride or ephedrine. VOLUME 15, MARCH 1965

Chest roentgenographic examination showed no obvious break in the pacemaker wires. Under local anesthesia a 1 inch incision was made in the left upper quadrant, over the wires palpated through the skin. These were brought out and connected to the transistorized external unit (Fig. 2). The heart immediately was paced at 90/min.; the child awoke and her condition improved. One week later a new internal pacemaker was placed, with the patient’s cardiac rate maintained by the external unit during the operation. Subsequently another wire breakage made it necessary to perform the same procedure again. This time, however, when the new pacemaker was placed, the battery was left within the chest cavity and attached to the undersurface of the anterior ribs. The battery was left in the chest cavity to avoid the continuous wire bending that occurs between the costal margin and the subcutaneously placed battery in the abdomen. The cardiac electrodes of the earlier pacemaker were left in the heart, and the wires were brought out and buried subcutaneously in case of future pacemaker failure (Fig. 3). Since then the child has attended school and led an active

life.

DISCUSSION In the case of complete

ment of an internal

heart block, the placepermanent pacemaker is a

406

Kahn,

Stern, Sigmann

safe procedure, provided the patient’s heart is artificially paced during the operation. In adult patients this can be accomplished by placing a cardiac catheter electrode in the right Some children, ventricle before the operation.2 however, find it difficult to tolerate this type of pacemaker and cannot cooperate in the proWe feel that the simple method we cedure. used for maintaining the heart rate in our patient, as illustrated in Figure 2, was a lifesaving procedure. During the last operation on this patient in which the pacemaker and its electrodes were placed in the thoracic cage, separate electrodes were left implanted in the myocardium and the wires brought out subcutaneously in the chest. This will allow the attachment of a transistorized external unit through a small cutaneous incision This if the internal pacemaker fails again. method of attaching an external pacemaker as an emergency measure under local anesthesia

and Sloan

can be applied to any type of pacemaker (Fig. 3).

failure

SUMMARY

A simple emergency method for handling pacemaker failures, devised under the. pressure of an actual emergency in a young child, can be extended to all types of pacemaker failure by placing “spare” electrodes in the myocardium and bringing the wires to an accessible subAt the time cutaneous area on the chest wall. of pacemaker failure, these wires can be uncovered, with the patient under local anesthesia, and attached to a transistorized external pacemaker.

1.

REFERENCES LILLEHEI, C. W., SELLERS, R. D., BONNABEAU, R. C. and ELIOT, R. S. Chronic postsurgical complete .J. Thoracic & Cardiovas. Surg., 46: heart block.

436, 1963. 2. FURMAN, S., SCHWEDEL, J. B., ROBINSON, G.

and HURWITT, E. S. Use of an intracardiac pacemaker in the control of heart block. Surgery, 49 : 98, 1961.

THE AMERICAN JOURNAL OF CARDIOLOGY