- Email: [email protected]
Long-term follow-up of transvenous cardiac pacing in children
Aprii ;, ‘986
MlCHAEL L. EPSTEIN, MD DANIEL @. KNAUF, MD JAMES A. ALEXANDER, MD
A
ggressive diagnosis and treatment, both medical and surgical, for congenital or acquired heart disease in children have resulted in an increased need for permanent cardiac pacing systems. However, frequent premature pacemaker revisions have been necessary for many reasons, including lead fractures, noncapture due to increasing threshold, and wound infection or skin breakdown over the pacemaker generator.1-3 Most pacemaker systems in children have used epicardial leads because of concern for lead dislodgement or damage to intracardiac structures, large lead size relative to small venous access, and difficulty in implanting relatively large pacemaker generators in a suitable prepectoral location. Recent changes in design of pacemaker generators and leads have made use of transvenous systems more tenable even in younger children who require permanent cardiac pacing.4 However, little information has been reported regarding long-term results of transvenous pacemakers in children. To evaluate the long-term results of transvenous pacemaker insertion in children, we reviewed records of patients in whom these systems had been From the Division of Cardiology, Department of Pediatrics and the Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida 32610. Manuscript received February 21, 1985; revised manuscript received August 28, 1985, accepted September 3,1985.
TABLE I
Clinical
WE
AMERICAN
~0UiWA.i
Summary of Patient Population
JA ae JB NB AC NJ RK KM SR BY Totals
Age (yr/mo) at TV PM Placement 914 916 914 1215 IO/IO 1019 918 IO/O IO/7 513
Diagnosis TGA ECD’ CHB ASD VI” ECD” ECD TGA VI’ TGA”
No. of Procedures
Volume 57
88%
implanted at the University of Florida. Records of children younger than 16 years who received permanent pacemaker systems between 1968 and 1983 (inclusive] were reviewed. To evaluate the long-term efficacy of the transvenous Iead system, patients were excluded if the pacemaker had not been inserted at least I year before the end of the evaluation period. Specifically, we determined age at first pacemaker as we11as age at first transvenous pacemaker implantation. We also recorded indication for pacemaker use, presence of underlying congenital heart disease and reasons for revisions. We identified IO patients who satisfied the above criteria. AlI patients are alive and well and free of symptoms of arrhythmias. There have been no apparent adverse sequelae from the transvenous lead based on results of history, physical examination and routine outpatient laboratory studies. No additional tests were performed to identify possible complications such as pulmonary emboli. The indication for pacemaker implantation was sinus node dysfunction in 4 patients (I of whom also had atrioventricular node dysfunction) and atrioventricuJar block in 6. One patient had congenital heart block and a structurally normal heart. A pacemaker was implanted in this patient for symptomatic bradycardia. Mine of the IO patients had structural congenital heart disease: transposition of the great arteries in 3 patients, endocardial cushion defect in 3, ventricular inversion in 2 and atrial septal defect in 1 patient. The 9 patients with structural heart disease all required pacemaker implantation after surgical repair of the defect. Five of the pacemakers implanted postoperatively were necessary in the perioperative period. Mean patient age at the time of transvenous pacemaker implantation was 9 years, 9 months (range 5 years, 3 months to 12 years, 5 months) (Table I). In 5 patients an epicardial lead system had been implanted previously. The average length of foIlow-up from time of initial (epicardial or transvenous] pacemaker system im-
indication
Pt
OF CARDiOLOGY
Procedures Since TV PM
Lead Fracture, Dislodgement
for Revision Generator Failure
Other
1 4 1 2 2 7 5 1 2 6
0 1 0 1 0 4 4 0 0 3
0 0 0 1 0 2 1 0 0 2
0 0 0 0 0 2 3 0 0 0
0 I+ 0 0 0 0 0 0 0 1%
31
13
6
5
2
* Previous epicardial lead system. t Tricuspid valve replacement. t Infection. ASD = atrial septal defect; CHB = congenital heart block; ECD = endocardial cushion defect; TGA = transposition of the great arteries; TV PM = transvenous pacemaker: VI = ventricular inversion.
890
BRIEF
REPORTS
In this group of patients the cumulative number of patient-years with a transvenous pacemaker was almost 44 years (range 10 months to more than 9 years). JB Thirteen reoperations were necessary, resulting in an NB average readmission interval of 40.5 months. Need for AC pacemaker revision was not related to age at implantaNJ tion, era in which the transvenous lead was inserted or RK duration of follow-up. Pacemaker revision was indiKM cated for circumstances that were unique to the indiSR vidual patient. BY The average readmission interval of 40.5 months compares favorably with recent series that describe I I1 I I I I I I1 I, IO I5 5 follow-up results on the use of pacemakers in children. PACING DURATION (YEARS) Dunnigan et al5 recently described 26 patients in whom epicardial pacemaker systems had been imTV LEAD 0 planted initially. These patients required an average EPI LEAD m admission interval of 31 months, and 16 of 34 reoperaBOTH m tions were due to lead problems. Furman and Young1 reported 19 patients in whom the average admission FIGURE 1. Duration of transvenous (TV), epicardial (EPI) or both interval was 15 months. Thirteen of the 19 patients had lead systems. transvenous lead systems and only 6 of 62 reoperations were due to lead fracture. Fifty-one patients with sick sinus syndrome were recently described by Gillette et plantation was 7 years [range 16 months to 15.5 years) al.” Nine of the patients had endocardial leads and (Fig. 1). Transvenous pacemakers are presently or had ‘fbllow-up of this subgroup was 6 to 18 months. Only 7 been in place for 10 months to 9.3 years (mean 4 years, reoperations were necessary for the entire group, 1 3 months]. In 5 patients transvenous pacemakers had involving a transvenous lead. This series indicates imbeen implanted as the initial mode of pacing. Three of proved durability of epicardial and transvenous lead these have required no revisions 16,34 and 54 months systems in children during that follow-up period. after implantation. In 4 patients the transvenous sysIn another report Gillette et al4 reported the feasitem replaced the epicardial lead. In 1 patient, the bility of using today’s more improved transvenous transvenous lead was placed in the atrium for atriopacemaker lead and generator systems in children. ventricular sequential pacing using the previously They implanted transvenous pacemakers in 48 paplaced epicardial lead to pace the ventricle. tients who were older than 7 years and weighed at Three of the 10 patients no longer have transvenous least 15 kg. Their early follow-up results are encouragsystems in place. In patient BB the transvenous lead ing. As in our patients, no adverse sequelae from use of had previously replaced a nonfunctioning ventricular transvenous leads were apparent. epicardial lead system. Thirty-nine months after inOur study shows that transvenous pacemaker syssertion of the transvenous unit the system, although tems can be used in children for long-term pacing. The functioning normally, was changed to an epicardial frequency of the need for reoperation compares favorlead because of the necessity for tricuspid valve re- ably with that for epicardial pacemaker systems. Adplacement. In patient NB another transvenous unit vantages include avoidance of a thoracotomy, probawas replaced with an epicardial lead system 10 bility of a shorter hospital stay and a decrease in cost of months after implantation because of fracture of the the procedure. Smaller pacemaker generators are transvenous lead. In patient RK an epicardial unit was available for use in younger children. Further iminserted more than 9 years after initial transvenous provement in lead design may decrease the number of pacemaker implantation because of fracture of the hospitalizations for premature revision of permanent transvenous lead. transvenous pacemaker systems. In these 10 patients 31 pacemaker-related operaAcknowledgment: We gratefully acknowledge the tions were performed over 70.3 patient-years (Table I). During 43.8 patient-years in which transvenous secretarial assistance of Penny Johnson. pacemaker systems were used, 13 reoperations were References necessary. Six operations in 4 patients were required 1. Furman S, Young D. Cardiac pacing in children and adolescents. Am J for lead fractures or dislodgement and 5 reoperaCardiol 1977;39:55&558. tions were necessary for generator replacement in 2 2. Waelkens JJJ.Cardiac pacemakers in infants and children. Pediatr Cardiol 1982;3:337-340. patients. PJ,Nicoloff DM, Moller JH. Post-operative complete heart block None of the reoperations performed in patients in3. Hofschire 84 children treated with and without cardiac pacing. Am J Cardiol with transvenous pacemakers was necessary for non- 1977;39:559-562. capture due to high threshold (exit block] at lead tip. 4. Gillette PC, Shannon C, Blair H, Garson A Jr, Porter CJ, McNamara DG. Transvenous pacing in pediatric patients. Am Heart J 1983;105:843-847. Various lead types were used, including 3 ventricu5. Dunnigan A, Benson W Jr, Moller JH. Follow-up of recently implanted lar screw-in leads, 4 ventricular tined leads, 2 unse- permanent pacing systems in pediatric patients: problems persist. Pediatr 198%3:3X?. cured ventricular leads, an abstract screw-in lead and Cardiol 6. Gillette PC, Shannon C, Garson A Jr. Porter CJ. Ott D. Cooley DA, McNaan atria1 tined lead. OnIy tined leads dislodged, but mara DC. Pacemaker treatment of sick sinus syndrome in children. JACC 19t33;1:1325-1329. both screw-in and tined ventricular leads fractured.
JA ee
MlCHAEL L. EPSTEIN, MD DANIEL @. KNAUF, MD JAMES A. ALEXANDER, MD
A
ggressive diagnosis and treatment, both medical and surgical, for congenital or acquired heart disease in children have resulted in an increased need for permanent cardiac pacing systems. However, frequent premature pacemaker revisions have been necessary for many reasons, including lead fractures, noncapture due to increasing threshold, and wound infection or skin breakdown over the pacemaker generator.1-3 Most pacemaker systems in children have used epicardial leads because of concern for lead dislodgement or damage to intracardiac structures, large lead size relative to small venous access, and difficulty in implanting relatively large pacemaker generators in a suitable prepectoral location. Recent changes in design of pacemaker generators and leads have made use of transvenous systems more tenable even in younger children who require permanent cardiac pacing.4 However, little information has been reported regarding long-term results of transvenous pacemakers in children. To evaluate the long-term results of transvenous pacemaker insertion in children, we reviewed records of patients in whom these systems had been From the Division of Cardiology, Department of Pediatrics and the Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida 32610. Manuscript received February 21, 1985; revised manuscript received August 28, 1985, accepted September 3,1985.
TABLE I
Clinical
WE
AMERICAN
~0UiWA.i
Summary of Patient Population
JA ae JB NB AC NJ RK KM SR BY Totals
Age (yr/mo) at TV PM Placement 914 916 914 1215 IO/IO 1019 918 IO/O IO/7 513
Diagnosis TGA ECD’ CHB ASD VI” ECD” ECD TGA VI’ TGA”
No. of Procedures
Volume 57
88%
implanted at the University of Florida. Records of children younger than 16 years who received permanent pacemaker systems between 1968 and 1983 (inclusive] were reviewed. To evaluate the long-term efficacy of the transvenous Iead system, patients were excluded if the pacemaker had not been inserted at least I year before the end of the evaluation period. Specifically, we determined age at first pacemaker as we11as age at first transvenous pacemaker implantation. We also recorded indication for pacemaker use, presence of underlying congenital heart disease and reasons for revisions. We identified IO patients who satisfied the above criteria. AlI patients are alive and well and free of symptoms of arrhythmias. There have been no apparent adverse sequelae from the transvenous lead based on results of history, physical examination and routine outpatient laboratory studies. No additional tests were performed to identify possible complications such as pulmonary emboli. The indication for pacemaker implantation was sinus node dysfunction in 4 patients (I of whom also had atrioventricular node dysfunction) and atrioventricuJar block in 6. One patient had congenital heart block and a structurally normal heart. A pacemaker was implanted in this patient for symptomatic bradycardia. Mine of the IO patients had structural congenital heart disease: transposition of the great arteries in 3 patients, endocardial cushion defect in 3, ventricular inversion in 2 and atrial septal defect in 1 patient. The 9 patients with structural heart disease all required pacemaker implantation after surgical repair of the defect. Five of the pacemakers implanted postoperatively were necessary in the perioperative period. Mean patient age at the time of transvenous pacemaker implantation was 9 years, 9 months (range 5 years, 3 months to 12 years, 5 months) (Table I). In 5 patients an epicardial lead system had been implanted previously. The average length of foIlow-up from time of initial (epicardial or transvenous] pacemaker system im-
indication
Pt
OF CARDiOLOGY
Procedures Since TV PM
Lead Fracture, Dislodgement
for Revision Generator Failure
Other
1 4 1 2 2 7 5 1 2 6
0 1 0 1 0 4 4 0 0 3
0 0 0 1 0 2 1 0 0 2
0 0 0 0 0 2 3 0 0 0
0 I+ 0 0 0 0 0 0 0 1%
31
13
6
5
2
* Previous epicardial lead system. t Tricuspid valve replacement. t Infection. ASD = atrial septal defect; CHB = congenital heart block; ECD = endocardial cushion defect; TGA = transposition of the great arteries; TV PM = transvenous pacemaker: VI = ventricular inversion.
890
BRIEF
REPORTS
In this group of patients the cumulative number of patient-years with a transvenous pacemaker was almost 44 years (range 10 months to more than 9 years). JB Thirteen reoperations were necessary, resulting in an NB average readmission interval of 40.5 months. Need for AC pacemaker revision was not related to age at implantaNJ tion, era in which the transvenous lead was inserted or RK duration of follow-up. Pacemaker revision was indiKM cated for circumstances that were unique to the indiSR vidual patient. BY The average readmission interval of 40.5 months compares favorably with recent series that describe I I1 I I I I I I1 I, IO I5 5 follow-up results on the use of pacemakers in children. PACING DURATION (YEARS) Dunnigan et al5 recently described 26 patients in whom epicardial pacemaker systems had been imTV LEAD 0 planted initially. These patients required an average EPI LEAD m admission interval of 31 months, and 16 of 34 reoperaBOTH m tions were due to lead problems. Furman and Young1 reported 19 patients in whom the average admission FIGURE 1. Duration of transvenous (TV), epicardial (EPI) or both interval was 15 months. Thirteen of the 19 patients had lead systems. transvenous lead systems and only 6 of 62 reoperations were due to lead fracture. Fifty-one patients with sick sinus syndrome were recently described by Gillette et plantation was 7 years [range 16 months to 15.5 years) al.” Nine of the patients had endocardial leads and (Fig. 1). Transvenous pacemakers are presently or had ‘fbllow-up of this subgroup was 6 to 18 months. Only 7 been in place for 10 months to 9.3 years (mean 4 years, reoperations were necessary for the entire group, 1 3 months]. In 5 patients transvenous pacemakers had involving a transvenous lead. This series indicates imbeen implanted as the initial mode of pacing. Three of proved durability of epicardial and transvenous lead these have required no revisions 16,34 and 54 months systems in children during that follow-up period. after implantation. In 4 patients the transvenous sysIn another report Gillette et al4 reported the feasitem replaced the epicardial lead. In 1 patient, the bility of using today’s more improved transvenous transvenous lead was placed in the atrium for atriopacemaker lead and generator systems in children. ventricular sequential pacing using the previously They implanted transvenous pacemakers in 48 paplaced epicardial lead to pace the ventricle. tients who were older than 7 years and weighed at Three of the 10 patients no longer have transvenous least 15 kg. Their early follow-up results are encouragsystems in place. In patient BB the transvenous lead ing. As in our patients, no adverse sequelae from use of had previously replaced a nonfunctioning ventricular transvenous leads were apparent. epicardial lead system. Thirty-nine months after inOur study shows that transvenous pacemaker syssertion of the transvenous unit the system, although tems can be used in children for long-term pacing. The functioning normally, was changed to an epicardial frequency of the need for reoperation compares favorlead because of the necessity for tricuspid valve re- ably with that for epicardial pacemaker systems. Adplacement. In patient NB another transvenous unit vantages include avoidance of a thoracotomy, probawas replaced with an epicardial lead system 10 bility of a shorter hospital stay and a decrease in cost of months after implantation because of fracture of the the procedure. Smaller pacemaker generators are transvenous lead. In patient RK an epicardial unit was available for use in younger children. Further iminserted more than 9 years after initial transvenous provement in lead design may decrease the number of pacemaker implantation because of fracture of the hospitalizations for premature revision of permanent transvenous lead. transvenous pacemaker systems. In these 10 patients 31 pacemaker-related operaAcknowledgment: We gratefully acknowledge the tions were performed over 70.3 patient-years (Table I). During 43.8 patient-years in which transvenous secretarial assistance of Penny Johnson. pacemaker systems were used, 13 reoperations were References necessary. Six operations in 4 patients were required 1. Furman S, Young D. Cardiac pacing in children and adolescents. Am J for lead fractures or dislodgement and 5 reoperaCardiol 1977;39:55&558. tions were necessary for generator replacement in 2 2. Waelkens JJJ.Cardiac pacemakers in infants and children. Pediatr Cardiol 1982;3:337-340. patients. PJ,Nicoloff DM, Moller JH. Post-operative complete heart block None of the reoperations performed in patients in3. Hofschire 84 children treated with and without cardiac pacing. Am J Cardiol with transvenous pacemakers was necessary for non- 1977;39:559-562. capture due to high threshold (exit block] at lead tip. 4. Gillette PC, Shannon C, Blair H, Garson A Jr, Porter CJ, McNamara DG. Transvenous pacing in pediatric patients. Am Heart J 1983;105:843-847. Various lead types were used, including 3 ventricu5. Dunnigan A, Benson W Jr, Moller JH. Follow-up of recently implanted lar screw-in leads, 4 ventricular tined leads, 2 unse- permanent pacing systems in pediatric patients: problems persist. Pediatr 198%3:3X?. cured ventricular leads, an abstract screw-in lead and Cardiol 6. Gillette PC, Shannon C, Garson A Jr. Porter CJ. Ott D. Cooley DA, McNaan atria1 tined lead. OnIy tined leads dislodged, but mara DC. Pacemaker treatment of sick sinus syndrome in children. JACC 19t33;1:1325-1329. both screw-in and tined ventricular leads fractured.
JA ee