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Long-Term Follow-Up of Permanent Transvenous Pacing Systems Preserved During Tricuspid Valve Replacement
Long-Term Follow-Up of Permanent Transvenous Pacing Systems Preserved During Tricuspid Valve Replacement J. Ernesto Molina, MD, PhD, Connie L. Roberts, RN, MS, and David G. Benditt, MD Divisions of Cardiothoracic Surgery and Cardiology, Electrophysiology Section, University of Minnesota, Medical School, Minneapolis, Minnesota
FEATURE ARTICLES
Patients undergoing tricuspid valve replacement who already have a transvenous pacemaker system in the right ventricle are often recommended to have the ventricular lead removed and an epicardial system implanted. However, as a rule, the reliability of endocardial transvenous pacemaker leads has been superior to epicardial systems. Therefore, if the pacemaker lead in the ventricle is still performing well, it may be preferable to
leave it in place. In this communication, we present the long-term follow-up results leaving the pacer lead in place by securing it in a position outside the prosthetic valve without interfering with the function of the prosthetic valve.
A
nary and tricuspid regurgitation developed years later. At reoperation, the aortic, pulmonary, and tricuspid valves were replaced with St. Jude prostheses (St. Jude Medical). A large perforation in the tricuspid leaflet caused by the pacemaker lead was found, rendering a plasty repair unsuitable. The pacemaker lead was excluded leaving it outside the tricuspid valve. Currently, he is actively working as a college teacher with a wellfunctioning pacemaker more than 10 years later.
lthough most of the reported series of tricuspid valve replacements include from 4% to 13% of patients who already have a transvenous pacer system in place [1–3], the authors either do not indicate how the pacing leads were handled, they infer their removal [1], or they clearly recommend their removal and replacement with an epicardial system [4]. However, the reliability of endocardial pacemaker leads has been superior to that of epicardial systems [5]. Therefore, if the pacemaker lead in the ventricle is still performing well, it may be preferable to leave it in place.
Technique Patient 1 Patient 1 is a female who was born with a bicuspid aortic valve who had subacute bacterial endocarditis develop with severe aortic valve regurgitation and a fistula to the right atrium at age 49. After undergoing two corrective surgeries she had a complete heart block develop. A transvenous pacemaker was implanted. During a third cardiac surgery the aortic, mitral, and tricuspid valves were replaced with St. Jude prostheses (St. Jude Medical, St. Paul, MN). The pacemaker lead was positioned outside the tricuspid valve (Figs 1 and 2). She is asymptomatic 9 years after her last operation.
Patient 2 Patient 2 is a male who was born with tetralogy of Fallot corrected in 1972. Later he had a complete heart block develop, and a pacemaker was implanted. Severe pulmo-
(Ann Thorac Surg 2010;89:318 –20) © 2010 by The Society of Thoracic Surgeons
Patient 3 Patient 3 is a female who was born with tetralogy of Fallot, which was corrected in infancy. Heart failure developed therafter with a 3-degree atrioventricular block; a pacemaker implantation was performed on June 19, 1981. She deteriorated and on September 28, 1998, she underwent mitral, pulmonary, and tricuspid valve replacements with St. Jude prostheses. The pacing lead was positioned outside the tricuspid valve. She recovered well and currently it has been 10 years since the last operation.
Patient 4 Patient 4 is male who was born with corrected transposition of the great vessels and severe pulmonary stenosis. After several corrective operations, a complete heart block occurred for which a pacemaker was implanted. Due to failure of previous repairs, the patient underwent a new intracardiac repair entailing pulmonary, mitral, and tricuspid valves replacements with St. Jude prostheses. The pacemaker lead was excluded and positioned
Accepted for publication March 12, 2009. Address correspondence to Dr Molina, Division of Cardiothoracic Surgery, University of Minnesota Medical Center, 420 Delaware St. SE, MMC 207, Minneapolis, MN 55455; e-mail: [email protected].
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
Dr Benditt discloses that he has a financial relationship with Medtronic Inc.
0003-4975/10/$36.00 doi:10.1016/j.athoracsur.2009.03.037
Ann Thorac Surg 2010;89:318 –20
HOW TO DO IT MOLINA ET AL TRICUSPID VALVE REPLACEMENT WITH PACEMAKER LEAD IN PLACE
319
outside the tricuspid valve. The patient is currently practicing as a dentist with a well-functioning pacemaker system 11 years later.
Technique The native valve was removed without disturbing the pacemaker lead, which was either fibrosed and attached to the walls of the cardiac chambers, or in one case free, but without redundant loops in the ventricle. The prosthetic valve was positioned and secured in place as illustrated in Figure 1. Mattress stitches were placed on both sides of the lead and closer together at the level of the skirt prosthesis.
Follow-Up The time elapsed from the original pacemaker implant to the time the tricuspid valves were replaced varied from 1 to 18 years, and the years under observation since the tricuspid valve was implanted extended from 9 to 11 years. The types of leads implanted are Medtronic models 5034 and 4068 (Medtronic Inc, Minneapolis, MN), and Boston Scientific Inc (previously Guidant-CPI) model 4130 (Boston Scientific, Natick, MA).
This communication illustrates the long-term results of implementing this technique previously reported with
Fig 1. Implant of a tricuspid valve prosthesis leaving the transvenous pacemaker lead in the right ventricle undisturbed. The mattress stitches are placed one on each side of the lead placing them close together on the skirt side of the prosthesis.
Fig 2. Postoperative radiographic appearance of the excluded transvenous pacemaker lead in patient 1. The radiopaque rings indicate the positions of the tricuspid, mitral, and aortic valve prosthesis with all St. Jude types (St. Jude Medical, St. Paul, MN).
short-term follow-up by Aris and colleagues [6] in 2004 and with a longer period of observation by Lin and colleagues [7] in 2005. Our findings indicate that not only is it feasible to retain a well-functioning lead, but that excellent lead function can be maintained for many years. Based on our experience, the practice of removing the endocardial pacemaker leads in patients undergoing tricuspid valve replacement, and providing a new epicardial system no longer seems necessary. The only theoretical disadvantage of implementing this technique is that management becomes complex if an infection occurs. The greatest risk will be at the time of the pulse generator replacement, since the infection rate is higher at the time of replacement than at original implant [8]. Consequently, replacement of these units should always be conducted with the greatest care and preferably in the operating suite rather than in the “hybrid” cardiac catheterization laboratory. If ever any of these leads would be considered for removal, this will not be feasible using the routine endovascular extraction techniques, but it will require an open procedure; neither in the Lin and colleagues’ [7] series nor in our own has this situation been presented as of yet. Another point of consideration is the possibility of these leads to malfunction as the period of follow-up prolongs. In that eventuality there is always the possibility of implanting another transvenous lead via the coronary sinus.
FEATURE ARTICLES
Comment
320
HOW TO DO IT MOLINA ET AL TRICUSPID VALVE REPLACEMENT WITH PACEMAKER LEAD IN PLACE
References 1. Nakano K, Koyanagi H, Hashimoto A, et al. Tricuspid valve replacement with the bileaflet St. Jude medical valve prosthesis. J Thorac Cardiovasc Surg 1994;108:888 –92. 2. Singh AK, Feng WC, Sanofsky SJ. Long-term results of St. Jude medical valve in the tricuspid position. Ann Thorac Surg 1992;54:538 – 41. 3. Ratnatunga CP, Edwards MB, Dore CJ, et al. Tricuspid valve replacement: UK heart valve registry mid-term results comparing mechanical and biological prostheses. Ann Thorac Surg 1998;66:1940 –7. 4. McCarthy PM, Bhudia SK, Rajeswaran J, et al. Tricuspid valve repair: durability and risk factors for failure. J Thorac Cardiovasc Surg 2004;127:674 – 85.
Ann Thorac Surg 2010;89:318 –20
5. Esperer HD, Mahmoud FO, von der Emde J. Is epicardial dual chamber pacing a realistic alternative to endocardial DDD pacing? Initial results of a prospective study. PACE 1992;15: 155– 61. 6. Aris A, Callejo F, Cobiella J, et al. Tricuspid valve replacement in the presence of an endocardial pacemaker electrode. J Heart Valve Dis 2004;13:523– 4. 7. Lin G, Mishimura RA, Connolly HM, et al. Severe symptomatic tricuspid valve regurgitation due to permanent pacemaker or implantable cardioverter-defibrillator leads. J Am Coll Cardiol 2005;45:1672–5. 8. Harcombe AA, Newell SA, Ludman PF, et al. Late complications following permanent pacemaker implantation or elective unit replacement. Heart 1998;80:240 – 4.
FEATURE ARTICLES
FEATURE ARTICLES
Patients undergoing tricuspid valve replacement who already have a transvenous pacemaker system in the right ventricle are often recommended to have the ventricular lead removed and an epicardial system implanted. However, as a rule, the reliability of endocardial transvenous pacemaker leads has been superior to epicardial systems. Therefore, if the pacemaker lead in the ventricle is still performing well, it may be preferable to
leave it in place. In this communication, we present the long-term follow-up results leaving the pacer lead in place by securing it in a position outside the prosthetic valve without interfering with the function of the prosthetic valve.
A
nary and tricuspid regurgitation developed years later. At reoperation, the aortic, pulmonary, and tricuspid valves were replaced with St. Jude prostheses (St. Jude Medical). A large perforation in the tricuspid leaflet caused by the pacemaker lead was found, rendering a plasty repair unsuitable. The pacemaker lead was excluded leaving it outside the tricuspid valve. Currently, he is actively working as a college teacher with a wellfunctioning pacemaker more than 10 years later.
lthough most of the reported series of tricuspid valve replacements include from 4% to 13% of patients who already have a transvenous pacer system in place [1–3], the authors either do not indicate how the pacing leads were handled, they infer their removal [1], or they clearly recommend their removal and replacement with an epicardial system [4]. However, the reliability of endocardial pacemaker leads has been superior to that of epicardial systems [5]. Therefore, if the pacemaker lead in the ventricle is still performing well, it may be preferable to leave it in place.
Technique Patient 1 Patient 1 is a female who was born with a bicuspid aortic valve who had subacute bacterial endocarditis develop with severe aortic valve regurgitation and a fistula to the right atrium at age 49. After undergoing two corrective surgeries she had a complete heart block develop. A transvenous pacemaker was implanted. During a third cardiac surgery the aortic, mitral, and tricuspid valves were replaced with St. Jude prostheses (St. Jude Medical, St. Paul, MN). The pacemaker lead was positioned outside the tricuspid valve (Figs 1 and 2). She is asymptomatic 9 years after her last operation.
Patient 2 Patient 2 is a male who was born with tetralogy of Fallot corrected in 1972. Later he had a complete heart block develop, and a pacemaker was implanted. Severe pulmo-
(Ann Thorac Surg 2010;89:318 –20) © 2010 by The Society of Thoracic Surgeons
Patient 3 Patient 3 is a female who was born with tetralogy of Fallot, which was corrected in infancy. Heart failure developed therafter with a 3-degree atrioventricular block; a pacemaker implantation was performed on June 19, 1981. She deteriorated and on September 28, 1998, she underwent mitral, pulmonary, and tricuspid valve replacements with St. Jude prostheses. The pacing lead was positioned outside the tricuspid valve. She recovered well and currently it has been 10 years since the last operation.
Patient 4 Patient 4 is male who was born with corrected transposition of the great vessels and severe pulmonary stenosis. After several corrective operations, a complete heart block occurred for which a pacemaker was implanted. Due to failure of previous repairs, the patient underwent a new intracardiac repair entailing pulmonary, mitral, and tricuspid valves replacements with St. Jude prostheses. The pacemaker lead was excluded and positioned
Accepted for publication March 12, 2009. Address correspondence to Dr Molina, Division of Cardiothoracic Surgery, University of Minnesota Medical Center, 420 Delaware St. SE, MMC 207, Minneapolis, MN 55455; e-mail: [email protected].
© 2010 by The Society of Thoracic Surgeons Published by Elsevier Inc
Dr Benditt discloses that he has a financial relationship with Medtronic Inc.
0003-4975/10/$36.00 doi:10.1016/j.athoracsur.2009.03.037
Ann Thorac Surg 2010;89:318 –20
HOW TO DO IT MOLINA ET AL TRICUSPID VALVE REPLACEMENT WITH PACEMAKER LEAD IN PLACE
319
outside the tricuspid valve. The patient is currently practicing as a dentist with a well-functioning pacemaker system 11 years later.
Technique The native valve was removed without disturbing the pacemaker lead, which was either fibrosed and attached to the walls of the cardiac chambers, or in one case free, but without redundant loops in the ventricle. The prosthetic valve was positioned and secured in place as illustrated in Figure 1. Mattress stitches were placed on both sides of the lead and closer together at the level of the skirt prosthesis.
Follow-Up The time elapsed from the original pacemaker implant to the time the tricuspid valves were replaced varied from 1 to 18 years, and the years under observation since the tricuspid valve was implanted extended from 9 to 11 years. The types of leads implanted are Medtronic models 5034 and 4068 (Medtronic Inc, Minneapolis, MN), and Boston Scientific Inc (previously Guidant-CPI) model 4130 (Boston Scientific, Natick, MA).
This communication illustrates the long-term results of implementing this technique previously reported with
Fig 1. Implant of a tricuspid valve prosthesis leaving the transvenous pacemaker lead in the right ventricle undisturbed. The mattress stitches are placed one on each side of the lead placing them close together on the skirt side of the prosthesis.
Fig 2. Postoperative radiographic appearance of the excluded transvenous pacemaker lead in patient 1. The radiopaque rings indicate the positions of the tricuspid, mitral, and aortic valve prosthesis with all St. Jude types (St. Jude Medical, St. Paul, MN).
short-term follow-up by Aris and colleagues [6] in 2004 and with a longer period of observation by Lin and colleagues [7] in 2005. Our findings indicate that not only is it feasible to retain a well-functioning lead, but that excellent lead function can be maintained for many years. Based on our experience, the practice of removing the endocardial pacemaker leads in patients undergoing tricuspid valve replacement, and providing a new epicardial system no longer seems necessary. The only theoretical disadvantage of implementing this technique is that management becomes complex if an infection occurs. The greatest risk will be at the time of the pulse generator replacement, since the infection rate is higher at the time of replacement than at original implant [8]. Consequently, replacement of these units should always be conducted with the greatest care and preferably in the operating suite rather than in the “hybrid” cardiac catheterization laboratory. If ever any of these leads would be considered for removal, this will not be feasible using the routine endovascular extraction techniques, but it will require an open procedure; neither in the Lin and colleagues’ [7] series nor in our own has this situation been presented as of yet. Another point of consideration is the possibility of these leads to malfunction as the period of follow-up prolongs. In that eventuality there is always the possibility of implanting another transvenous lead via the coronary sinus.
FEATURE ARTICLES
Comment
320
HOW TO DO IT MOLINA ET AL TRICUSPID VALVE REPLACEMENT WITH PACEMAKER LEAD IN PLACE
References 1. Nakano K, Koyanagi H, Hashimoto A, et al. Tricuspid valve replacement with the bileaflet St. Jude medical valve prosthesis. J Thorac Cardiovasc Surg 1994;108:888 –92. 2. Singh AK, Feng WC, Sanofsky SJ. Long-term results of St. Jude medical valve in the tricuspid position. Ann Thorac Surg 1992;54:538 – 41. 3. Ratnatunga CP, Edwards MB, Dore CJ, et al. Tricuspid valve replacement: UK heart valve registry mid-term results comparing mechanical and biological prostheses. Ann Thorac Surg 1998;66:1940 –7. 4. McCarthy PM, Bhudia SK, Rajeswaran J, et al. Tricuspid valve repair: durability and risk factors for failure. J Thorac Cardiovasc Surg 2004;127:674 – 85.
Ann Thorac Surg 2010;89:318 –20
5. Esperer HD, Mahmoud FO, von der Emde J. Is epicardial dual chamber pacing a realistic alternative to endocardial DDD pacing? Initial results of a prospective study. PACE 1992;15: 155– 61. 6. Aris A, Callejo F, Cobiella J, et al. Tricuspid valve replacement in the presence of an endocardial pacemaker electrode. J Heart Valve Dis 2004;13:523– 4. 7. Lin G, Mishimura RA, Connolly HM, et al. Severe symptomatic tricuspid valve regurgitation due to permanent pacemaker or implantable cardioverter-defibrillator leads. J Am Coll Cardiol 2005;45:1672–5. 8. Harcombe AA, Newell SA, Ludman PF, et al. Late complications following permanent pacemaker implantation or elective unit replacement. Heart 1998;80:240 – 4.
FEATURE ARTICLES