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Long-term survival of elderly patients after pacemaker implantation
Long-term survival of elderly patients after pacemaker implantation Shlomo Amikam, M.D. Joseph Lemer, F.R.C.S. Nathan Roguin, M.D. Haran Peleg, M.D. Egon Riss, M.D., M.Sc., F.A.C.C. Haifa, Israel
Permanent cardiac pacing has become the accepted therapy for symptomatic atrioventricular block. 1 In recent years the indications have been extended to include other conditions such as sick-sinus syndrome, 2 carotid sinus syndrome, 3 and certain forms of brady- and tachyarrythmias. 4-3 The majority of patients requiring pacemaker implantation are in the sixth, seventh, and eighth decades of life, but a significant number of patients are in the younger age groups. So far, little attention has been given to the particular problems and outcome of pacemaker implantations in the most advanced age groups. We have reported previously on the long-term survival of 150 consecutive patients with implanted pacemakers. ~ Our results were closely comparable with those of previous similar studies, indicating a markedly improved prognosis in these patients. 7-9 The purpose of the present report is to focus attention on patients most advanced in age with particular regard to the long-term prognosis in this selected group. This series consists of 80 patients who were in the eighth and ninth decades of life at the time of the implantation and who were followed for a period of 1 to 8 years. Subjects and methods Patients. Between April, 1965, and November, 1974, 170 patients underwent pacemaker implan-
From the Department of Cardiology and Cardiac Surgery, Rambam University Hospital, Aba Khoushy School of Medicine, Haifa, Israel. Received for publication March 11, 1975. Reprint requests: Dr. S. Amikam, Department of Cardiology, Rambam Government Hospital, Haifa, Israel.
April, 1976, Vol. 91, No. 4, pp. 445-449
tations at the Rambam Government Hospital, Haifa. These patients were followed regularly at the hospital pacemaker clinic at intervals of 3 to 6 months. Of these patients we selected 80 who had been over the age of 70 years at the time of implantation and had been followed for at least 1 year. The average age of this group of patients was 75.4 years, the oldest being 87 years. Table I shows the age distribution of these 80 patients, of whom 50 were male and 30 were female. Twentyone patients (26.3 per cent) had clinical evidence of coronary heart disease (previous myocardial infarction or angina pectoris); 17 (21.3 per cent) had diabetes mellitus; 67 had atrioventricular block which was considered to be idiopathic; four had sick-sinus syndrome. None of the patients in the study had had heart block which developed directly after acute myocardial infarction or cardiac surgery. The electrocardiographic (ECG) findings at the time of implantation were as follows: (1) complete atrioventricular block (permanent or transient) in 59 patients (73.9 per cent); (2) second-degree atrioventricular block in 11 patients (13.5 per cent); (3) trifascicular block, without evidence of more advanced heart block, in six patients (7.6 per cent); (4) ECG findings characteristic of sick-sinus syndrome in four (5 per cent). The indications for pacemaker implantation were based on clinical grounds and were of two kinds: (1) Stokes-Adams attacks, which were present in 52 of the cases (65 per cent); (2) symptoms or signs of chronic low cardiac output causing dizziness, fatigue, dyspnea on effort, angina, or overt signs of heart failure, which occurred in 28 patients (35 per cent). In no case
A m e r i c a n Heart Journal
445
A m i k a m et al.
Table I. Age distribution
Age group
I
No. of patients
70:74 75-79
40 27
80-84 85-87
8 5
Table II. Causes of death
No. of patients
Cause of death I. Postoperative death:
Ventricular fibrillation (seventh day) Septicaemia (fifth day)
1 1
Results
II. Late death:
Heart failure Malignancy Complicationsfollowingfracture of femur Sub-arachnoid hemorrhage Cause unknown{death outside hospital)
7 3 2 1 6
Total
Table III.
21
Survival rate
Follow-up period (yr.)
No. of patients
No. of survivors
(%)
1 2 3 4 5
80 67 54 37 24
72 55 40 25 14
90.0 82.1 74.1 67.2 58.3
was a pacemaker implanted in an asymptomatic patient, whatever the ECG findings. Methods. During the initial period (1965 to 1967) only epicardial electrodes were used for pacemaker implantation. This procedure requires general anesthesia and thoracotomy. Since 1968 the transvenous endocardial method of electrode implantation has been employed almost exclusively. This procedure requires local anesthesia only and permits an earlier return to activity. In this method the endocardial electrode is introduced through the left cephalic vein in the deltopectoral triangle, or by way of another nearby pectoral tributary of the left subclavian vein. The pacemaker unit is implanted in a subcutaneous pocket in the left anterior chest wall. The unit
446
was implanted in a subpectoral muscle pocket in particularly thin patients (of more frequent occurrence in the elderly). In 67 patients a transvenous endocardial electrode was used, and in 13 patients an epicardial electrode. The pulse generators used were of two* types: (1) "fixed-rate," implanted in 30 patients, and (2) "demand" (ventricular-inhibited) implanted in 50 patients. In the initial period only fixed-rate pulse generators were used. Since 1968 we have used almost exclusively the demand type. Presently, whenever a battery replacement is required we usually replace the fixed-rate unit with a demand unit, providing t h a t the ventricular excitation threshold is satisfactory.
Deaths. There were 21 deaths in this group of 80 patients: two patients (2.5 per cent} died during the immediate postoperative period and 19 patients during a period of 3 months to 6 years after the implantation. The causes of death are listed in Table II. Of the two patients who died in the immediate postoperative period, one developed ventricular fibrillation on the seventh postoperative day, following demand endocardial pacemaker implantation, which was resistant to repeated attempts of D.C. defibrillations. The second patient was a 70-year-old diabetic woman who developed local infection at the site of the implanted epicardial pacemaker unit, with subsequent purulent pericarditis and septicaemia. Of the 19 patients who died in the follow-up period, causes of death are known to us in 13. In six patients who died outside the hospital the cause of death is uncertain. In these patients the possibility that death was due to failure of one of the pacemaker components cannot be ruled out; however, it was not the cause in any of the 13 9known cases. Survival. All patients were followed for at least 1 year after the pacemaker implantation; 67 of these could be followed up for 2 years, 54 f o r 3 years, 37 for 4 years, and 24 for 5 years after implantation. Table III shows the survival rates in these groups of Patients. At present we have in our follow-up two patients who are alive 6 years after implantation; three patients, 7 years after implantation; three patients 8 years after imptan*Medtronic models no. 5860, 5860-C, 5862-C, 5841, 5842, 5942.
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tation; all were at least 70 years old a t the time of the implantation. Complications. Twelve of t h e 13 p a t i e n t s with epicardial pacemakers survived the operation. Of the survivors, nine patients required readmission during the follow-up period because of r e c u r r e n c e of s y m p t o m s due to cessation of pacing. T h e causes were: fracture of epicardial electrode (three p a t i e n t s - i n one p a t i e n t two episodes), elevated stimulation threshold (two patients), and early failure of b a t t e r y (four patients). It should be noted t h a t early b a t t e r y failure occurred only in the initial years (1966 to 1969). Sixty-six of the 67 patients with endocardial pacemakers survived the operation. Of the survivors, cessation of pacing occured in 18 patients. T h e causes were: displacement of endocardial electrode tip (14 p a t i e n t s - i n t h r e e of t h e m it caused in addition perforation of the m y o c a r dium), exit block (three patients), and f a u l t y connection between p a c e m a k e r unit and electrode (one patient). O t h e r complications, which appeared during the follow-up period in the endocardial group but did not interfere with pacing, were: local h e m a t o m a at implant site (six patients), skin erosion due to pressure of the implanted unit (three patients), and local infection at implant site (three patients). In three patients satisfactory long-term pacing was obtained with an endocardial electrode placed in the coronary sinus. Only in one case of the endocardial group, early b a t t e r y failure appeared {year 1971). None of the complications listed above caused death. T h e postoperative and late complications are summarized in T a b l e IV. T h e most c o m m o n complication was displacem e n t of the endocardial electrode. It occurred most frequently in the early years of our endocardial pacemaker experience, b u t b e c a m e rare in recent years. Morbidity. Of the 61 surviving patients being followed by us, 42 are enjoying good h e a l t h and are normally active for their age. S o m e of t h e m still do a full day's work. N i n e t e e n patients are limited in their activity b u t still are able to live independently, none of t h e m being bedridden or requiring nursing assistance. T h i r t y patients of the 61 are receiving t h e r a p y for congestive h e a r t failure, which is mild in half of t h e m and of moderate to severe in the rest. Five of our patients u n d e r w e n t successful surgery since the p a c e m a k e r i m p l a n t a t i o n : one
American Heart Journal
Table IV. Complications No. of episodes
Complications J
Epicardial electrode (total 13 patients):
Fracture of electrode Threshold elevation Early battery failure Total
4 2 4 10
Endocardial electrode (total 67 patients):
Displacement of electrode Perforation Exit block Faulty connection between battery and electrode Early failure of battery Hematoma at implantation site Skin erosion over implantation site Local infection at implantatio~ site Total
11 3 3 1 1 6 ~- 3 3 31
patient had l a p a r o t o m y for polyposis of the colon, one patient had c y s t o s t o m y with resection of carcinoma of the bladder, one patient had a cataract extraction, and two patients u n d e r w e n t prostatectomy. Two patients are psychotic and have frequent admissions to m e n t a l institutes. It is of interest t h a t none of 61 survivors and the 13 patients who died, in whom the cause of d e a t h is known, suffered an acute m y o c a r d i a l infarction or cerebrovascular event, since the p a c e m a k e r implantation. Discussion
The m o r t a l i t y rate in patients who suffered Stokes-Adams attacks due to complete A-V block, treated medically, was reported to be 50 per cent within the first y e a r since the onset of clinical manifestations and 75 per cent within 5 years. 1~ T h e i n t r o d u c t i o n of p a c e m a k e r s changed dramatically the course of this disease. Presently 80 to 90 per cent of these patients can expect to survive 1 year following p a c e - m a k e r implantation and 50 to 60 per cent can expect to remain alive 5 years thereafter. 7-9 In a previous study ~ we reported on the survival rate of 150 patients who had been followed for a period of 1 to 5 years after pacemaker i m p l a n t a t i o n : 90.1 per cent survived 1 year after i m p l a n t a t i o n ; 82.4 per cent, 2 years; 75.4 per cent, 3 years; 70.5 per cent, 4 years; 66.7 per cent were alive out of the group which had been followed for 5 years. We assumed
447
A m i k a m et al.
that the higher survival rate in our series as compared with other similar studies was due to the fact that our series included a relatively high proportion of young patients with congenital heart block. In the present study we selected the patients of the most advanced age group. The long-term follow-up survival rates were surprisingly similar to those of our study which included all age groups for the first 3 years of follow-up (90.0, 82.1, and 74.1 per cent, respectively). Only in the fourth and fifth years after implantation did the survival rates in the most advanced age groups decrease, compared to the rates in all age groups (67.2 and 58.2 per cent, respectively), as could be anticipated from the natural life expeCtancy in this age group. These results indicate that permanent pacing in the elderly patient is justified not only for the immediate need t o manage an acute situation (Stokes-Adams syndrome) but also because it significantly prolongs life. Little attention has been paid to this aspect of pacemaker implantation, and we could find only one comment on this subject in the current literature. Obel, Marchand, and Scott-Millar 1~ pointed out t h a t in their series of 120 patients, "Pacing the elderly was at least as rewarding as the younger group." We believe that the main reason for these encouraging results has been the introduction of the transvenous endocardial electrode in pacemaker implantation: This method does not require general anesthesia and thoracotomy and has therefore greatly reduced the operative risk. This method also allows early mobilization, which has a special significance in this group of patients. Regular supervision in a special pacemaker clinic is mandatory and provides early detection of battery depletion or other pacemaker malfunctions, e.g., failure to pace, failure to sense, fracture or displacement of electrode, skin erosion, etc.; treatment can thus begin at an early stage. The complications associated with the endocardial electrode were: displacement, perforation, exit block, skin erosion, and local infection. The complications of the epicardial group were fracture of the electrode and elevation of stimulation threshold. These complications were frequent but they were easily corrected and proved fatal in only one case of generalized sepsis in a diabetic patient of the epicardial group, The two groups are not comparable with regard to the postopera-
448
tive mortality rate and the long-term complication incidence. This is because most of our epicardial implantations were done in the early years of our experience, whereas the endocardial implantation were performed mostly in recent years. Furthermore, presently the endocardial method enables pacemaker implantation in patients who probably would have been rejected if the epicardial method had been the only one available. The incidence of postoperative complications decreased steadily over the years, presumably as a result of increased experience and improved technical reliability of the pacemakers. An innovation which reduced markedly electrode tip displacement was the use of a "butterfly" anchor, thus ensuring good fixation of the endocardial electrode to the vein of introduction. Davidson and associates 14investigated the incidence of myocardial infarction and cerebrovascular accidents over a prolonged period following pacemaker implantation. They showed that there was no increase in the incidence of these episodes as compared to the expected incidence for this age group. We can support these findings as we have not seen a case of myocardial infarction or cerebrovascular accident among our 80 patients (except for one death from subarachnoid hemorrhage). In a significant number of patients, in whom the pacemaker was implanted because of Stokes-Adams attacks, congestive heart failure appeared during the follow-up period, In patients in whom refractory congestive heart failure with complete heart block was the indication for pacing, improvement of the heart failure was usually achieved. We became convinced that the quality of life in the elderly patient suffering from atrioventricular block is much improved following implantation. These patients become again independent for their daily needs, their mental processes are preserved, and some o f them are even able to continue working far beyond the age of retirement. All these benefits are in addition to the relief from a constant fear of a recurrence of a Stokes-Adams attack. We conclude that pacemaker implantation in the most elderly patients with complete heart block is beneficial not only for the treatment of the acute problem but also because it prolongs life and greatly enhances its quality. The dependence of these previously gravely disabled patients on their families and society is thus reduced.
April, 1976, Vol. 91, No. 4
Pacemaker implantation in elderly patients Summary T h e f o l l o w - u p o f 80 p a t i e n t s a b o v e t h e a g e o f 70 y e a r s w i t h i m p l a n t e d p a c e m a k e r s is d e s c r i b e d . T h e s e p a t i e n t s w e r e t h e m o s t a d v a n c e d in a g e f r o m a t o t a l g r o u p o f 150 w i t h i m p l a n t e d p a c e m a k e r s . T h e i r a g e s r a n g e d f r o m 70 t o 87 y e a r s , w i t h a n a v e r a g e o f 75.4 y e a r s ; 50 w e r e m a l e a n d 30 were f e m a l e . A n e p i c a r d i a l e l e c t r o d e w a s i m p l a n t e d in 13 p a t i e n t s a n d a n e n d o c a r d i a l e l e c t r o d e in 67. T h e p a c e m a k e r w a s i m p l a n t e d in 76 p a t i e n t s for s y m p t o m a t i c atrioventricular b l o c k a n d in f o u r p a t i e n t s for s i c k - s i n u s s y n d r o m e . T w o p a t i e n t s (2.5 p e r c e n t ) d i e d d u r i n g t h e p o s t o p e r a t i v e p e r i o d a n d 19 p a t i e n t s w i t h i n a period of 3 months to 6 years after the implantation. T h e s u r v i v a l r a t e s w e r e : 1 y e a r , 90.0 p e r cent; 2 y e a r s , 82.1 p e r c e n t ; 3 y e a r s , 74.1 p e r c e n t ; 4 y e a r s , 67.2 p e r c e n t ; 5 y e a r s , 58.3 p e r c e n t . T h e s e survival rates were surprisingly similar, for the first 3 y e a r s o f f o l l o w - u p , t o t h o s e o f o u r a n d others' previous studies, which included all age groups. T h e s u r v i v a l r a t e s i n t h e m o s t a d v a n c e d age g r o u p s d e c r e a s e d in c o m p a r i s o n o n l y in t h e f o u r t h a n d fifth y e a r s a f t e r t h e i m p l a n t a t i o n . There was no evidence of new episodes of myocardial infarction among this group of patients during the follow-up period. W e c o n c l u d e t h a t e v e n in p a t i e n t s of t h e m o s t advanced age groups the implantation of an e n d o c a r d i a l p a c e m a k e r s i g n i f i c a n t l y p r o l o n g s life, improves its quality, and this at a low operative risk.
2. Conde, C. A., Leppo, J., Lipski, J., Stimmel, B., Litwak, R., Donoso, E., and Dack, S.: Effectiveness of pacemaker treatment in bradycardia-tachycardia syndrome, Am. J. Cardiol. 32:209, 1973. 3. Voss, D. M., and Magnin, G. E.: Demand pacing and carotid sinus syncope, AM. HEART J. 79:544, 1970. 4. Kitchen, J. G., and Goldreyer, B. N.: Demand pacemaker for refractory paroxysmal supra-ventricular tachycardia, N. Engl. J. Med. 287:596, 1972. 5.. Williams, D. O., and Davison, P. H.: Long-term treatment of refractory supraventricular tachycardia by patient-controlled inductive atrial pacing, Br. Heart. J. 36:336, 1974. 6. Amikam, S., Roguin, N., Markiewicz, W., Niremberg, V., Hammerman, H., Peleg, H., Lemer, J., Adler, D., and Riss, E.: 150 pacemaker implantations, J. Isr. Med. Assoc. 87:439, 1974. 7. Chardack, W. M., Gage, A. A., Federico, A. J., Schimert, G., and Greatbatch, W.: Five years' clinical experience with an implantable pacemaker: An appraisal, Surgery 58:915, 1965. 8. Johansson, B. W.: Longevity in complete heart block, Ann. N. Y. Acad. Sci. 167:1031, 1969. 9. Zion, M. M., Marchand, P. E., and Obel, I. W. P.: Longterm prognosis after cardiac pacing in atrioventricular block, Br. Heart J. 35:359, 1973. 10. Penton, G. B., Midler, H., and Levine, S. A.: Some clinical features of complete heart block, Circulation 13:801, 1956. 11. Friedberg, C. K., Donoso, E., and Stein, W. G.: Nonsurgical acquired heart block, Ann. N. Y. Acad. Sci. 1 1 1:835, 1964. 12. Rowe, J. C., and White, P. D. Complete heart block: A follow-up study, Ann, Intern. Med. 49:260, 1958. 13. Obel, I. W. P., Marchand, P. E., and Scott-Millar, R. W.: Cardiac pacemaking: Experience with the first 120 patients treated in Johannesburg, S. Afr. Med. J. 46:2002, 1972. 14. Davidson, D. M., Braak, C. A., Preston, T. A., and Judge, R. D.: Permanent ventricular pacing: Effect on longterm survival, congestive heart failure and subsequent myocardial infarction and stroke, Ann. Intern. Med. 77:345, 1972.
REFERENCES 1. Dack, S., and Donoso, E.: Heart block with StokesAdams syndrome: Indications and results of cardiac pacing, Ann. N. Y. Acad. Sci. 167:519, 1969.
American Heart Journal
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Permanent cardiac pacing has become the accepted therapy for symptomatic atrioventricular block. 1 In recent years the indications have been extended to include other conditions such as sick-sinus syndrome, 2 carotid sinus syndrome, 3 and certain forms of brady- and tachyarrythmias. 4-3 The majority of patients requiring pacemaker implantation are in the sixth, seventh, and eighth decades of life, but a significant number of patients are in the younger age groups. So far, little attention has been given to the particular problems and outcome of pacemaker implantations in the most advanced age groups. We have reported previously on the long-term survival of 150 consecutive patients with implanted pacemakers. ~ Our results were closely comparable with those of previous similar studies, indicating a markedly improved prognosis in these patients. 7-9 The purpose of the present report is to focus attention on patients most advanced in age with particular regard to the long-term prognosis in this selected group. This series consists of 80 patients who were in the eighth and ninth decades of life at the time of the implantation and who were followed for a period of 1 to 8 years. Subjects and methods Patients. Between April, 1965, and November, 1974, 170 patients underwent pacemaker implan-
From the Department of Cardiology and Cardiac Surgery, Rambam University Hospital, Aba Khoushy School of Medicine, Haifa, Israel. Received for publication March 11, 1975. Reprint requests: Dr. S. Amikam, Department of Cardiology, Rambam Government Hospital, Haifa, Israel.
April, 1976, Vol. 91, No. 4, pp. 445-449
tations at the Rambam Government Hospital, Haifa. These patients were followed regularly at the hospital pacemaker clinic at intervals of 3 to 6 months. Of these patients we selected 80 who had been over the age of 70 years at the time of implantation and had been followed for at least 1 year. The average age of this group of patients was 75.4 years, the oldest being 87 years. Table I shows the age distribution of these 80 patients, of whom 50 were male and 30 were female. Twentyone patients (26.3 per cent) had clinical evidence of coronary heart disease (previous myocardial infarction or angina pectoris); 17 (21.3 per cent) had diabetes mellitus; 67 had atrioventricular block which was considered to be idiopathic; four had sick-sinus syndrome. None of the patients in the study had had heart block which developed directly after acute myocardial infarction or cardiac surgery. The electrocardiographic (ECG) findings at the time of implantation were as follows: (1) complete atrioventricular block (permanent or transient) in 59 patients (73.9 per cent); (2) second-degree atrioventricular block in 11 patients (13.5 per cent); (3) trifascicular block, without evidence of more advanced heart block, in six patients (7.6 per cent); (4) ECG findings characteristic of sick-sinus syndrome in four (5 per cent). The indications for pacemaker implantation were based on clinical grounds and were of two kinds: (1) Stokes-Adams attacks, which were present in 52 of the cases (65 per cent); (2) symptoms or signs of chronic low cardiac output causing dizziness, fatigue, dyspnea on effort, angina, or overt signs of heart failure, which occurred in 28 patients (35 per cent). In no case
A m e r i c a n Heart Journal
445
A m i k a m et al.
Table I. Age distribution
Age group
I
No. of patients
70:74 75-79
40 27
80-84 85-87
8 5
Table II. Causes of death
No. of patients
Cause of death I. Postoperative death:
Ventricular fibrillation (seventh day) Septicaemia (fifth day)
1 1
Results
II. Late death:
Heart failure Malignancy Complicationsfollowingfracture of femur Sub-arachnoid hemorrhage Cause unknown{death outside hospital)
7 3 2 1 6
Total
Table III.
21
Survival rate
Follow-up period (yr.)
No. of patients
No. of survivors
(%)
1 2 3 4 5
80 67 54 37 24
72 55 40 25 14
90.0 82.1 74.1 67.2 58.3
was a pacemaker implanted in an asymptomatic patient, whatever the ECG findings. Methods. During the initial period (1965 to 1967) only epicardial electrodes were used for pacemaker implantation. This procedure requires general anesthesia and thoracotomy. Since 1968 the transvenous endocardial method of electrode implantation has been employed almost exclusively. This procedure requires local anesthesia only and permits an earlier return to activity. In this method the endocardial electrode is introduced through the left cephalic vein in the deltopectoral triangle, or by way of another nearby pectoral tributary of the left subclavian vein. The pacemaker unit is implanted in a subcutaneous pocket in the left anterior chest wall. The unit
446
was implanted in a subpectoral muscle pocket in particularly thin patients (of more frequent occurrence in the elderly). In 67 patients a transvenous endocardial electrode was used, and in 13 patients an epicardial electrode. The pulse generators used were of two* types: (1) "fixed-rate," implanted in 30 patients, and (2) "demand" (ventricular-inhibited) implanted in 50 patients. In the initial period only fixed-rate pulse generators were used. Since 1968 we have used almost exclusively the demand type. Presently, whenever a battery replacement is required we usually replace the fixed-rate unit with a demand unit, providing t h a t the ventricular excitation threshold is satisfactory.
Deaths. There were 21 deaths in this group of 80 patients: two patients (2.5 per cent} died during the immediate postoperative period and 19 patients during a period of 3 months to 6 years after the implantation. The causes of death are listed in Table II. Of the two patients who died in the immediate postoperative period, one developed ventricular fibrillation on the seventh postoperative day, following demand endocardial pacemaker implantation, which was resistant to repeated attempts of D.C. defibrillations. The second patient was a 70-year-old diabetic woman who developed local infection at the site of the implanted epicardial pacemaker unit, with subsequent purulent pericarditis and septicaemia. Of the 19 patients who died in the follow-up period, causes of death are known to us in 13. In six patients who died outside the hospital the cause of death is uncertain. In these patients the possibility that death was due to failure of one of the pacemaker components cannot be ruled out; however, it was not the cause in any of the 13 9known cases. Survival. All patients were followed for at least 1 year after the pacemaker implantation; 67 of these could be followed up for 2 years, 54 f o r 3 years, 37 for 4 years, and 24 for 5 years after implantation. Table III shows the survival rates in these groups of Patients. At present we have in our follow-up two patients who are alive 6 years after implantation; three patients, 7 years after implantation; three patients 8 years after imptan*Medtronic models no. 5860, 5860-C, 5862-C, 5841, 5842, 5942.
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Pacemaker implantation in elderly patients
tation; all were at least 70 years old a t the time of the implantation. Complications. Twelve of t h e 13 p a t i e n t s with epicardial pacemakers survived the operation. Of the survivors, nine patients required readmission during the follow-up period because of r e c u r r e n c e of s y m p t o m s due to cessation of pacing. T h e causes were: fracture of epicardial electrode (three p a t i e n t s - i n one p a t i e n t two episodes), elevated stimulation threshold (two patients), and early failure of b a t t e r y (four patients). It should be noted t h a t early b a t t e r y failure occurred only in the initial years (1966 to 1969). Sixty-six of the 67 patients with endocardial pacemakers survived the operation. Of the survivors, cessation of pacing occured in 18 patients. T h e causes were: displacement of endocardial electrode tip (14 p a t i e n t s - i n t h r e e of t h e m it caused in addition perforation of the m y o c a r dium), exit block (three patients), and f a u l t y connection between p a c e m a k e r unit and electrode (one patient). O t h e r complications, which appeared during the follow-up period in the endocardial group but did not interfere with pacing, were: local h e m a t o m a at implant site (six patients), skin erosion due to pressure of the implanted unit (three patients), and local infection at implant site (three patients). In three patients satisfactory long-term pacing was obtained with an endocardial electrode placed in the coronary sinus. Only in one case of the endocardial group, early b a t t e r y failure appeared {year 1971). None of the complications listed above caused death. T h e postoperative and late complications are summarized in T a b l e IV. T h e most c o m m o n complication was displacem e n t of the endocardial electrode. It occurred most frequently in the early years of our endocardial pacemaker experience, b u t b e c a m e rare in recent years. Morbidity. Of the 61 surviving patients being followed by us, 42 are enjoying good h e a l t h and are normally active for their age. S o m e of t h e m still do a full day's work. N i n e t e e n patients are limited in their activity b u t still are able to live independently, none of t h e m being bedridden or requiring nursing assistance. T h i r t y patients of the 61 are receiving t h e r a p y for congestive h e a r t failure, which is mild in half of t h e m and of moderate to severe in the rest. Five of our patients u n d e r w e n t successful surgery since the p a c e m a k e r i m p l a n t a t i o n : one
American Heart Journal
Table IV. Complications No. of episodes
Complications J
Epicardial electrode (total 13 patients):
Fracture of electrode Threshold elevation Early battery failure Total
4 2 4 10
Endocardial electrode (total 67 patients):
Displacement of electrode Perforation Exit block Faulty connection between battery and electrode Early failure of battery Hematoma at implantation site Skin erosion over implantation site Local infection at implantatio~ site Total
11 3 3 1 1 6 ~- 3 3 31
patient had l a p a r o t o m y for polyposis of the colon, one patient had c y s t o s t o m y with resection of carcinoma of the bladder, one patient had a cataract extraction, and two patients u n d e r w e n t prostatectomy. Two patients are psychotic and have frequent admissions to m e n t a l institutes. It is of interest t h a t none of 61 survivors and the 13 patients who died, in whom the cause of d e a t h is known, suffered an acute m y o c a r d i a l infarction or cerebrovascular event, since the p a c e m a k e r implantation. Discussion
The m o r t a l i t y rate in patients who suffered Stokes-Adams attacks due to complete A-V block, treated medically, was reported to be 50 per cent within the first y e a r since the onset of clinical manifestations and 75 per cent within 5 years. 1~ T h e i n t r o d u c t i o n of p a c e m a k e r s changed dramatically the course of this disease. Presently 80 to 90 per cent of these patients can expect to survive 1 year following p a c e - m a k e r implantation and 50 to 60 per cent can expect to remain alive 5 years thereafter. 7-9 In a previous study ~ we reported on the survival rate of 150 patients who had been followed for a period of 1 to 5 years after pacemaker i m p l a n t a t i o n : 90.1 per cent survived 1 year after i m p l a n t a t i o n ; 82.4 per cent, 2 years; 75.4 per cent, 3 years; 70.5 per cent, 4 years; 66.7 per cent were alive out of the group which had been followed for 5 years. We assumed
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that the higher survival rate in our series as compared with other similar studies was due to the fact that our series included a relatively high proportion of young patients with congenital heart block. In the present study we selected the patients of the most advanced age group. The long-term follow-up survival rates were surprisingly similar to those of our study which included all age groups for the first 3 years of follow-up (90.0, 82.1, and 74.1 per cent, respectively). Only in the fourth and fifth years after implantation did the survival rates in the most advanced age groups decrease, compared to the rates in all age groups (67.2 and 58.2 per cent, respectively), as could be anticipated from the natural life expeCtancy in this age group. These results indicate that permanent pacing in the elderly patient is justified not only for the immediate need t o manage an acute situation (Stokes-Adams syndrome) but also because it significantly prolongs life. Little attention has been paid to this aspect of pacemaker implantation, and we could find only one comment on this subject in the current literature. Obel, Marchand, and Scott-Millar 1~ pointed out t h a t in their series of 120 patients, "Pacing the elderly was at least as rewarding as the younger group." We believe that the main reason for these encouraging results has been the introduction of the transvenous endocardial electrode in pacemaker implantation: This method does not require general anesthesia and thoracotomy and has therefore greatly reduced the operative risk. This method also allows early mobilization, which has a special significance in this group of patients. Regular supervision in a special pacemaker clinic is mandatory and provides early detection of battery depletion or other pacemaker malfunctions, e.g., failure to pace, failure to sense, fracture or displacement of electrode, skin erosion, etc.; treatment can thus begin at an early stage. The complications associated with the endocardial electrode were: displacement, perforation, exit block, skin erosion, and local infection. The complications of the epicardial group were fracture of the electrode and elevation of stimulation threshold. These complications were frequent but they were easily corrected and proved fatal in only one case of generalized sepsis in a diabetic patient of the epicardial group, The two groups are not comparable with regard to the postopera-
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tive mortality rate and the long-term complication incidence. This is because most of our epicardial implantations were done in the early years of our experience, whereas the endocardial implantation were performed mostly in recent years. Furthermore, presently the endocardial method enables pacemaker implantation in patients who probably would have been rejected if the epicardial method had been the only one available. The incidence of postoperative complications decreased steadily over the years, presumably as a result of increased experience and improved technical reliability of the pacemakers. An innovation which reduced markedly electrode tip displacement was the use of a "butterfly" anchor, thus ensuring good fixation of the endocardial electrode to the vein of introduction. Davidson and associates 14investigated the incidence of myocardial infarction and cerebrovascular accidents over a prolonged period following pacemaker implantation. They showed that there was no increase in the incidence of these episodes as compared to the expected incidence for this age group. We can support these findings as we have not seen a case of myocardial infarction or cerebrovascular accident among our 80 patients (except for one death from subarachnoid hemorrhage). In a significant number of patients, in whom the pacemaker was implanted because of Stokes-Adams attacks, congestive heart failure appeared during the follow-up period, In patients in whom refractory congestive heart failure with complete heart block was the indication for pacing, improvement of the heart failure was usually achieved. We became convinced that the quality of life in the elderly patient suffering from atrioventricular block is much improved following implantation. These patients become again independent for their daily needs, their mental processes are preserved, and some o f them are even able to continue working far beyond the age of retirement. All these benefits are in addition to the relief from a constant fear of a recurrence of a Stokes-Adams attack. We conclude that pacemaker implantation in the most elderly patients with complete heart block is beneficial not only for the treatment of the acute problem but also because it prolongs life and greatly enhances its quality. The dependence of these previously gravely disabled patients on their families and society is thus reduced.
April, 1976, Vol. 91, No. 4
Pacemaker implantation in elderly patients Summary T h e f o l l o w - u p o f 80 p a t i e n t s a b o v e t h e a g e o f 70 y e a r s w i t h i m p l a n t e d p a c e m a k e r s is d e s c r i b e d . T h e s e p a t i e n t s w e r e t h e m o s t a d v a n c e d in a g e f r o m a t o t a l g r o u p o f 150 w i t h i m p l a n t e d p a c e m a k e r s . T h e i r a g e s r a n g e d f r o m 70 t o 87 y e a r s , w i t h a n a v e r a g e o f 75.4 y e a r s ; 50 w e r e m a l e a n d 30 were f e m a l e . A n e p i c a r d i a l e l e c t r o d e w a s i m p l a n t e d in 13 p a t i e n t s a n d a n e n d o c a r d i a l e l e c t r o d e in 67. T h e p a c e m a k e r w a s i m p l a n t e d in 76 p a t i e n t s for s y m p t o m a t i c atrioventricular b l o c k a n d in f o u r p a t i e n t s for s i c k - s i n u s s y n d r o m e . T w o p a t i e n t s (2.5 p e r c e n t ) d i e d d u r i n g t h e p o s t o p e r a t i v e p e r i o d a n d 19 p a t i e n t s w i t h i n a period of 3 months to 6 years after the implantation. T h e s u r v i v a l r a t e s w e r e : 1 y e a r , 90.0 p e r cent; 2 y e a r s , 82.1 p e r c e n t ; 3 y e a r s , 74.1 p e r c e n t ; 4 y e a r s , 67.2 p e r c e n t ; 5 y e a r s , 58.3 p e r c e n t . T h e s e survival rates were surprisingly similar, for the first 3 y e a r s o f f o l l o w - u p , t o t h o s e o f o u r a n d others' previous studies, which included all age groups. T h e s u r v i v a l r a t e s i n t h e m o s t a d v a n c e d age g r o u p s d e c r e a s e d in c o m p a r i s o n o n l y in t h e f o u r t h a n d fifth y e a r s a f t e r t h e i m p l a n t a t i o n . There was no evidence of new episodes of myocardial infarction among this group of patients during the follow-up period. W e c o n c l u d e t h a t e v e n in p a t i e n t s of t h e m o s t advanced age groups the implantation of an e n d o c a r d i a l p a c e m a k e r s i g n i f i c a n t l y p r o l o n g s life, improves its quality, and this at a low operative risk.
2. Conde, C. A., Leppo, J., Lipski, J., Stimmel, B., Litwak, R., Donoso, E., and Dack, S.: Effectiveness of pacemaker treatment in bradycardia-tachycardia syndrome, Am. J. Cardiol. 32:209, 1973. 3. Voss, D. M., and Magnin, G. E.: Demand pacing and carotid sinus syncope, AM. HEART J. 79:544, 1970. 4. Kitchen, J. G., and Goldreyer, B. N.: Demand pacemaker for refractory paroxysmal supra-ventricular tachycardia, N. Engl. J. Med. 287:596, 1972. 5.. Williams, D. O., and Davison, P. H.: Long-term treatment of refractory supraventricular tachycardia by patient-controlled inductive atrial pacing, Br. Heart. J. 36:336, 1974. 6. Amikam, S., Roguin, N., Markiewicz, W., Niremberg, V., Hammerman, H., Peleg, H., Lemer, J., Adler, D., and Riss, E.: 150 pacemaker implantations, J. Isr. Med. Assoc. 87:439, 1974. 7. Chardack, W. M., Gage, A. A., Federico, A. J., Schimert, G., and Greatbatch, W.: Five years' clinical experience with an implantable pacemaker: An appraisal, Surgery 58:915, 1965. 8. Johansson, B. W.: Longevity in complete heart block, Ann. N. Y. Acad. Sci. 167:1031, 1969. 9. Zion, M. M., Marchand, P. E., and Obel, I. W. P.: Longterm prognosis after cardiac pacing in atrioventricular block, Br. Heart J. 35:359, 1973. 10. Penton, G. B., Midler, H., and Levine, S. A.: Some clinical features of complete heart block, Circulation 13:801, 1956. 11. Friedberg, C. K., Donoso, E., and Stein, W. G.: Nonsurgical acquired heart block, Ann. N. Y. Acad. Sci. 1 1 1:835, 1964. 12. Rowe, J. C., and White, P. D. Complete heart block: A follow-up study, Ann, Intern. Med. 49:260, 1958. 13. Obel, I. W. P., Marchand, P. E., and Scott-Millar, R. W.: Cardiac pacemaking: Experience with the first 120 patients treated in Johannesburg, S. Afr. Med. J. 46:2002, 1972. 14. Davidson, D. M., Braak, C. A., Preston, T. A., and Judge, R. D.: Permanent ventricular pacing: Effect on longterm survival, congestive heart failure and subsequent myocardial infarction and stroke, Ann. Intern. Med. 77:345, 1972.
REFERENCES 1. Dack, S., and Donoso, E.: Heart block with StokesAdams syndrome: Indications and results of cardiac pacing, Ann. N. Y. Acad. Sci. 167:519, 1969.
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