Epicardial versus endocardial permanent pacing in adults with congenital heart disease

McLeod, Christopher J.; Jost, Christine H. Attenhofer; Warnes, Carole A.; Hodge, David O.; Hyberger, Linda K.; Connolly, Heidi M.; Asirvatham, Samuel J.; Dearani, Joseph A.; Hayes, David L.; Ammash, Naser M.

doi:10.1007/s10840-010-9494-4

Cited by 66 publications

(46 citation statements)

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“…[14][15][16] However, whether the presence of a PFO in most CIED recipients increases the risk of clinical strokes or transient ischemic attacks (TIAs) is unknown. Therefore, screening for a PFO is not routinely performed at the time of CIED implantation, and the presence or absence of a PFO does not affect the implant decision or strategy in current clinical practice.…”

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confidence: 99%

Stroke or Transient Ischemic Attack in Patients With Transvenous Pacemaker or Defibrillator and Echocardiographically Detected Patent Foramen Ovale

et al. 2013

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15% of patients within 2 weeks of device implantation without heparin prophylaxis, 8 and, at autopsy, pulmonary emboli were present in 21% of patients with CIEDs. 6 A study using intracardiac echocardiography at the time of a planned electrophysiological procedure found mobile thrombi attached to leads in 30% of patients. 9 These thrombi were rarely seen with the use of transthoracic echocardiography (TTE), reflecting their small size. Moreover, the presence of lead-related thrombi was associated with increased pulmonary artery systolic pressure, suggesting subclinical pulmonary embolic events.9 Elevated pulmonary artery pressures may in turn increase the likelihood of right-to-left shunting across a patent foramen ovale (PFO). Clinical Perspective on p 1441Background-A patent foramen ovale (PFO) may permit arterial embolization of thrombi that accumulate on the leads of cardiac implantable electronic devices in the right-sided cardiac chambers. We sought to determine whether a PFO increases the risk of stroke/transient ischemic attack (TIA) in patients with endocardial leads. Methods and Results-We retrospectively evaluated all patients who had endocardial leads implanted between January 1, 2000, and October 25, 2010, at Mayo Clinic Rochester. Echocardiography was used to establish definite PFO and non-PFO cohorts. The primary end point of stroke/TIA consistent with a cardioembolic etiology and the secondary end point of mortality during postimplantation follow-up were compared in PFO versus non-PFO patients with the use of Cox proportional hazards models. We analyzed 6075 patients (364 with PFO) followed for a mean 4.7±3.1 years. The primary end point of stroke/TIA was met in 30/364 (8.2%) PFO versus 117/5711 (2.0%) non-PFO patients (hazard ratio, 3.49; 95% confidence interval, 2.33-5.25; P<0.0001). The association of PFO with stroke/TIA remained significant after multivariable adjustment for age, sex, history of stroke/TIA, atrial fibrillation, and baseline aspirin/warfarin use (hazard ratio, 3.30; 95% confidence interval, 2.19-4.96; P<0.0001). There was no significant difference in all-cause mortality between PFO and non-PFO patients (hazard ratio, 0.91; 95% confidence interval, 0.77-1.07; P=0.25). Conclusions-In patients with endocardial leads, the presence of a PFO on routine echocardiography is associated with a substantially increased risk of embolic stroke/TIA. This finding suggests a role of screening for Up to 25% of the population may have a PFO detectable on autopsy, with persistence after the birth of a connection between the right and left atria. 10,11 In patients with elevated right-sided pressures, flow through a PFO provides a mechanism of blood flow from the right heart to the left-sided circulation. In patients with a PFO, endovascular leads may pose a unique hazard, because the thrombi that develop on leads may shunt across the PFO to the systemic circulation, resulting in ischemic cerebrovascular events or other systemic thromboembolisms. We have previously published 2 case series on device...

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Stroke or Transient Ischemic Attack in Patients With Transvenous Pacemaker or Defibrillator and Echocardiographically Detected Patent Foramen Ovale

et al. 2013

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“…The use of epicardial implantation was also more often associated with exit block -an excitability threshold too high for pacing to be possible, which requires the implantation of a new pacemaker. Despite the increasingly common use of epicardial electrodes releasing steroidal drugs, some authors claim that the average time of the correct functioning of epicardial pacemakers is only 4 years [2,16]. The application of epicardial electrodes onto the myocardium after opening the pericardial sac bears the risk of post-pericardiotomy syndrome and increases the likelihood of perioperative complications resulting from the immobilization of the patient.…”

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confidence: 99%

Congenital heart disease in children and adults Outcomes of long-term endocavitary cardiac pacing in children

Szklarz¹,

Jędrzejczyk-Patej²,

Czapla³

2013

kitp

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StreszczenieWstęp: Dzięki rozwojowi kardiologii i kardiochirurgii okresu noworodkowego, wczesnej diagnostyce wad wrodzonych oraz zaburzeń rytmu i przewodnictwa serca systematycznie obniża się wiek i zwiększa liczba dzieci i młodych dorosłych poddawanych procedurom elektrofizjologicznym. Dzieci wymagające leczenia stałą stymulacją serca stanowią 1-2% całej populacji kwalifikowanej do implantacji kardiostymulatora. Celem pracy było przedstawienie wyników leczenia stałą stymulacją serca u dzieci poddanych endokawitarnej implantacji kardiostymulatora w obserwacji długoterminowej. Materiał i metody: Obserwacji poddano grupę 106 dzieci do 12 lat po implantacji. Zakres wieku dzieci wynosił 2-17 lat, waga 13-58,8 kg. Wśród badanych było 91 dzieci z blokiem przedsionkowo-komorowym lub dysfunkcją węzła zatokowego po chirurgicznej korekcji wrodzonej wady serca, 7 pacjentów z wrodzonym całkowitym blokiem przedsionkowo-komorowym, 4 pacjentów z pozapalną niewydolnością węzła zatokowego, 4 pacjentów z objawową bradykardią po transplantacji serca. Wyniki: U wszystkich 106 pacjentów implantowano układ endokawitarny z rodzajem stymulacji zgodnym ze wskazaniami. Średni czas zabiegu wynosił 92 min, średni czas fluoroskopii 9 min 37 s. W obserwacji odległej średni czas żywotności baterii wynosił 5 lat. Wnioski: Przezżylna implantacja układu stymulującego jest metodą małoinwazyjną i możliwą do zastosowania u dzieci. Słowa kluczowe: endokawitarna stymulacja, stymulacja serca u dzieci.Kardiochirurgia i Torakochirurgia Polska 2013; 10 (3) 216 CONGENITAL HEART DISEASE IN CHILDREN AND ADULTS AbstractBackground: The development of neonatal cardiology and cardiac surgery, as well as the earlier diagnosis of congenital defects, arrhythmias, and cardiac conduction disorders, contributed to the systematic increase of the number of children and young adults undergoing electrophysiological procedures, as well as to the reduction of the age at which these procedures are performed. Children requiring permanent cardiac pacing constitute 1-2% of the entire population qualified for cardiac pacemaker implantation. The aim of this study was to present the results of permanent pacing therapy employed in children undergoing endocavitary pacemaker implantation in long-term follow-up. Material and methods: The study group included 106 children up to 12 years after pacemaker implantation. The age range of the children was 2-17 years, while their weight was between 13 and 58.8 kg. The group included 91 children after surgical repair of congenital heart defects, 7 patients with congenital complete atrioventricular block, 4 patients with postinflammatory sinus node dysfunction, and 4 patients with symptomatic bradycardia after heart transplantation. Results: All 106 patients were implanted with endocardial system types consistent with their indications for pacing. The mean duration of the procedure was 92 min, while the average duration of fluoroscopy was 9 min 37 s. The average battery lifespan in follow-up was 5 years. Conclusions: Transvenous pacemaker impl...

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“…Electrophysiological studies were performed using the Cardiolab System (6.8.1 release 2, GE Healthcare, Wauwatosa, Wisconsin) using standard cardiac stimulators. Regular bipolar configurations between electrodes arranged in parallel between lead arms (1–2, 3–4, 5–6 and 7–8) or serially along each arm (1–3, 2–4, 1–5) were used (Figure 3). Sensed signals were gained 500 times and processed with 30 – 500 Hz band pass and 60 Hz notch filters.…”

Section: Methodsmentioning

confidence: 99%

“…The alternative is the use of epicardial leads placed directly onto the left ventricle. However, this currently requires a surgical approach and there may need to be multiple revisions over time as these leads have an increased failure rate on long-term followup (4). With 2% of the adult population in the developed world currently suffering from heart failure, a rising prevalence as longevity increases, and with an estimated 5% to 10% of heart failure patients having an indication for CRT (5), there is an increasing role for more versatile pacing approaches to help overcome some of these limitations.…”

Section: Introductionmentioning

confidence: 99%

Percutaneous Epicardial Pacing Using a Novel Insulated Multi-Electrode Lead

Syed

DeSimone

Ebrille

et al. 2015

JACC: Clinical Electrophysiology

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Introduction Epicardial cardiac resynchronization therapy (CRT) permits unrestricted electrode positioning. However, this requires surgical placement of device leads and the risk of unwanted phrenic nerve stimulation. We hypothesized that shielded electrodes can capture myocardium without extracardiac stimulation. Methods In 6 dog and 5 swine experiments, we used a percutaneous approach to access the epicardial surface of the heart, and deploy novel leads housing multiple electrodes with selective insulation. Bipolar pacing thresholds at prespecified sites were tested compare electrode threshold data both facing towards and away from the epicardial surface. Results In 151 paired electrode recordings (70 in 6 dogs; 81 in 5 swine), thresholds facing myocardium were lower than facing away (median [IQR] mA: dogs 0.9 [0.4–1.6] vs 4.6 [2.1 to >10], p<0.0001; swine 0.5 [0.2–1] vs 2.5 [0.5–6.8], p<0.0001). Myocardial capture was feasible without extracardiac stimulation at all tested sites, with mean ± SE threshold margin 3.6±0.7 mA at sites of high output extracardiac stimulation (p=0.004). Conclusion Selective electrode insulation confers directional pacing to a multielectrode epicardial pacing lead. This device has the potential for a novel percutaneous epicardial resynchronization therapy that permits placement at an optimal pacing site, irrespective of the anatomy of the coronary veins or phrenic nerves.

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Epicardial versus endocardial permanent pacing in adults with congenital heart disease

Abstract: Permanent pacing in CHD is associated with considerable morbidity and the need for repeat intervention, especially in those with Ebstein's anomaly. Epicardial pacing systems appear to have a higher incidence of lead failure and are significantly less durable in this group.

Cited by 66 publications

References 22 publications

Stroke or Transient Ischemic Attack in Patients With Transvenous Pacemaker or Defibrillator and Echocardiographically Detected Patent Foramen Ovale

Stroke or Transient Ischemic Attack in Patients With Transvenous Pacemaker or Defibrillator and Echocardiographically Detected Patent Foramen Ovale

Congenital heart disease in children and adults Outcomes of long-term endocavitary cardiac pacing in children

Percutaneous Epicardial Pacing Using a Novel Insulated Multi-Electrode Lead

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