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Transvenous permanent pacemaker implantation in neonates
International Journal of Cardiology 75 (2000) 103–104 www.elsevier.com / locate / ijcard
Letter to the Editor
Transvenous permanent pacemaker implantation in neonates T. Hoorntje, J. Kammeraad, G. Bennink, N. Sreeram* Willielmina Children’ s Hospital, Post Box 85090, 3508 AB Utrecht, The Netherlands Received 24 March 2000; accepted 8 April 2000
Keywords: Transvenous permanent pacemaker; Implantation; Neonates
We describe a technique of transvenous permanent pacemaker implantation in neonates. Two consecutive neonates with congenital atrioventricular block and impaired ventricular function at birth underwent permanent pacemaker implantation via the transvenous route. The patients weighed 2.1 and 2.6 kg, respectively, and the pacemaker was implanted in both cases on day 2 of life. Informed consent was obtained from the parents for this procedure. Under general anesthesia, venous access was gained by percutaneous puncture of the left subclavian vein. A 7F unipolar or 6F bipolar steroideluting active fixation lead (Medtronic BY, The Netherlands) was introduced and fixed in the right ventricular apex in a standard fashion, via a 7F peelaway introducer. After good lead thresholds had been confirmed, the extravascular portion of the lead was tunnelled subcutaneously to the anterior abdominal wall. The generator (Medtronic Thera SR or St. Jude Microny SR) was implanted in the anterior abdominal wall via a small abdominal incision. The sleeve of the lead was secured subcutaneously at its entry point into the subclavian vein using non-absorbable suture material. At follow-up, excellent sensing and pacing thresholds were obtained in both patients. At 14-months*Corresponding author. Tel.: 131-30-250-4002; fax: 131-30-2505347. E-mail address: [email protected] (N. Sreeram).
of-age, patient 1 required lead advancement, as the intracardiac loop had straightened out. The abdominal incision was reopened, and the anchoring sleeve was also exposed. The non-absorbable suture around the sleeve was identified and cut. Using a standard stylet, the lead could easily be readvanced to create a loop in the atrium (Fig. 1). The sleeve was re-fixed, and the abdominal incision closed. Further follow-up for 12 months has been uneventful. Patient 2 has had no complications over a follow-up of 4 months. The choice of systems for permanent pacing in neonates has hitherto been dictated by patient size. However, lead performance and longevity are greater for transvenous steroid-eluting leads when compared with their epicardial equivalents [1]. Important considerations for transvenous pacing in neonates are: (1) techniques to accommodate for somatic growth, to prevent lead stretching and malfunction. We have opted to use active fixation leads, to provide stable lead position in the ventricle. This also allows a loop of lead to be left in the atrium to accommodate for growth; (2) choice of site for placement of the generator. In patients .3 kg weight, a single chamber generator can be positioned in the infraclavicular region, in a subpectoral position. In smaller patients, as described here, the generator is located in the anterior abdominal wall, as for a standard epicardial generator. The transvenous lead is then tunnelled to this location. Lead advancement is relatively simple.
0167-5273 / 00 / $ – see front matter 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S0167-5273( 00 )00275-8
104
T. Hoorntje et al. / International Journal of Cardiology 75 (2000) 103 – 104
Fig. 1. (a) Chest x ray 14 months after pacemaker implantation, showing straightening out of the lead due to somatic growth. (b) Chest x ray following advancement of the lead, with a loop in the atrium to accommodate for further somatic growth.
Vascular occlusions arising from indwelling leads are a potential long-term concern. Asymptomatic occlusion is commoner in adults, and may be less frequent in children [2]. Further advances in lead technology (smaller caliber leads or leads which can be introduced and positioned via a catheter) will only increase the versatility of the transvenous approach.
References [1] Till JA, Jones S, Rowland E, Shinebourne EA, Ward DE. Endocardial pacing in infants and children 15 kg or less in weight: medium-term follow-up. PACE 1990;13:1385–92. [2] Gillette PC, Ziegler V, Bradham X. Pediatric transvenous pacing: a concern for venous thromboembolism? PACE 1988;1(1):1935–9.
Letter to the Editor
Transvenous permanent pacemaker implantation in neonates T. Hoorntje, J. Kammeraad, G. Bennink, N. Sreeram* Willielmina Children’ s Hospital, Post Box 85090, 3508 AB Utrecht, The Netherlands Received 24 March 2000; accepted 8 April 2000
Keywords: Transvenous permanent pacemaker; Implantation; Neonates
We describe a technique of transvenous permanent pacemaker implantation in neonates. Two consecutive neonates with congenital atrioventricular block and impaired ventricular function at birth underwent permanent pacemaker implantation via the transvenous route. The patients weighed 2.1 and 2.6 kg, respectively, and the pacemaker was implanted in both cases on day 2 of life. Informed consent was obtained from the parents for this procedure. Under general anesthesia, venous access was gained by percutaneous puncture of the left subclavian vein. A 7F unipolar or 6F bipolar steroideluting active fixation lead (Medtronic BY, The Netherlands) was introduced and fixed in the right ventricular apex in a standard fashion, via a 7F peelaway introducer. After good lead thresholds had been confirmed, the extravascular portion of the lead was tunnelled subcutaneously to the anterior abdominal wall. The generator (Medtronic Thera SR or St. Jude Microny SR) was implanted in the anterior abdominal wall via a small abdominal incision. The sleeve of the lead was secured subcutaneously at its entry point into the subclavian vein using non-absorbable suture material. At follow-up, excellent sensing and pacing thresholds were obtained in both patients. At 14-months*Corresponding author. Tel.: 131-30-250-4002; fax: 131-30-2505347. E-mail address: [email protected] (N. Sreeram).
of-age, patient 1 required lead advancement, as the intracardiac loop had straightened out. The abdominal incision was reopened, and the anchoring sleeve was also exposed. The non-absorbable suture around the sleeve was identified and cut. Using a standard stylet, the lead could easily be readvanced to create a loop in the atrium (Fig. 1). The sleeve was re-fixed, and the abdominal incision closed. Further follow-up for 12 months has been uneventful. Patient 2 has had no complications over a follow-up of 4 months. The choice of systems for permanent pacing in neonates has hitherto been dictated by patient size. However, lead performance and longevity are greater for transvenous steroid-eluting leads when compared with their epicardial equivalents [1]. Important considerations for transvenous pacing in neonates are: (1) techniques to accommodate for somatic growth, to prevent lead stretching and malfunction. We have opted to use active fixation leads, to provide stable lead position in the ventricle. This also allows a loop of lead to be left in the atrium to accommodate for growth; (2) choice of site for placement of the generator. In patients .3 kg weight, a single chamber generator can be positioned in the infraclavicular region, in a subpectoral position. In smaller patients, as described here, the generator is located in the anterior abdominal wall, as for a standard epicardial generator. The transvenous lead is then tunnelled to this location. Lead advancement is relatively simple.
0167-5273 / 00 / $ – see front matter 2000 Elsevier Science Ireland Ltd. All rights reserved. PII: S0167-5273( 00 )00275-8
104
T. Hoorntje et al. / International Journal of Cardiology 75 (2000) 103 – 104
Fig. 1. (a) Chest x ray 14 months after pacemaker implantation, showing straightening out of the lead due to somatic growth. (b) Chest x ray following advancement of the lead, with a loop in the atrium to accommodate for further somatic growth.
Vascular occlusions arising from indwelling leads are a potential long-term concern. Asymptomatic occlusion is commoner in adults, and may be less frequent in children [2]. Further advances in lead technology (smaller caliber leads or leads which can be introduced and positioned via a catheter) will only increase the versatility of the transvenous approach.
References [1] Till JA, Jones S, Rowland E, Shinebourne EA, Ward DE. Endocardial pacing in infants and children 15 kg or less in weight: medium-term follow-up. PACE 1990;13:1385–92. [2] Gillette PC, Ziegler V, Bradham X. Pediatric transvenous pacing: a concern for venous thromboembolism? PACE 1988;1(1):1935–9.