Natural History and Predictors of Temporary Epicardial Pacemaker Wire Function in Patients after Open Heart Surgery

Elmi, Farhad; Tullo, Nicholas G.; Khalighi, Koroush

doi:10.1159/000067312

Cited by 42 publications

(38 citation statements)

References 13 publications

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“…Insertion can prolong the operative time and increase the risk of bleeding. Their extended use can result in failure of sensing or capturing [17]. During removal, patients are at risk of ventricular arrhythmias [18] and to a lesser extent bleeding due to injury of nearby structures [19-21].…”

Section: Discussionmentioning

confidence: 99%

Predictors of temporary epicardial pacing wires use after valve surgery

AlWaqfi

Ibrahim

Khader

et al. 2014

J Cardiothorac Surg

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BackgroundAlthough temporary cardiac pacing is infrequently needed, temporary epicardial pacing wires are routinely inserted after valve surgery. As they are associated with infrequent, but life threatening complications, and the decreased need for postoperative pacing in a group of low risk patients; this study aims to identify the predictors of temporary cardiac pacing after valve surgery.MethodsA retrospective analysis of data collected prospectively on 400 consecutive valve surgery patients between May 2002 and December 2012 was performed. Patients were grouped according to avoidance or insertion of temporary pacing wires, and were further subdivided according to temporary cardiac pacing need. Multiple logistic regression was used to determine the predictors of temporary cardiac pacing.Results170 (42.5%) patients did not have insertion of temporary pacing wires and none of them needed temporary pacing. 230 (57.5%) patients had insertion of temporary pacing wires and among these, only 55 (23.9%) required temporary pacing who were compared with the remaining 175 (76.1%) patients in the main analysis. The determinants of temporary cardiac pacing (adjusted odds ratios; 95% confidence interval) were as follows: increased age (1.1; 1.1, 1.3, p = 0.002), New York Heart Association class III- IV (5.6; 1.6, 20.2, p = 0.008) , pulmonary artery pressure ≥ 50 mmHg (22.0; 3.4, 142.7, p = 0.01), digoxin use (8.0; 1.3, 48.8, p = 0.024), multiple valve surgery (13.5; 1.5, 124.0, p = 0.021), aorta cross clamp time ≥ 60 minutes (7.8; 1.6, 37.2, p = 0.010), and valve annulus calcification (7.9; 2.0, 31.7, p = 0.003).ConclusionAlthough limited by sample size, the present results suggest that routine use of temporary epicardial pacing wires after valve surgery is only necessary for high risk patients. Preoperative identification and aggressive management of predictors of temporary cardiac pacing and the possible modulation of intraoperative techniques can decrease the need of temporary cardiac pacing. Prospective randomized controlled studies on a larger number of patients are necessary to draw solid conclusions regarding the selective use of temporary epicardial pacing wires in valve surgery.

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Section: Discussionmentioning

confidence: 99%

Predictors of temporary epicardial pacing wires use after valve surgery

AlWaqfi

Ibrahim

Khader

et al. 2014

J Cardiothorac Surg

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“…Au fil des jours, l'inflammation myocardique et la fibrose dé veloppé es autour du point d'insertion é picardique des é lectrodes requiè rent une intensité de stimulation de plus en plus grande pour pouvoir stimuler le myocarde. Il a é té dé crit dans la litté rature une augmentation des seuils de stimulation des é lectrodes unipolaires à partir du quatriè me jour postopé ratoire, ainsi qu'une dé gradation de la dé tection à partir du deuxiè me jour postopé ratoire [11].…”

Section: Types D'e´lectrodes E´picardiques Temporairesunclassified

Entraînement électrosystolique épicardique temporaire post-chirurgie cardiaque : modalités pratiques

Lazarescu

Mertès

Longrois³

2013

Annales Françaises d'Anesthésie et de Réanimation

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“…Increases in stimulation thresholds commonly occur after four days in both atrial and ventricular leads. Failure to pace is documented in more than 60% of wires placed in the right atrium and more than 80% of wires placed in the left atrium after five days (3,4). Furthermore, in acute postoperative periods, there is a potential proarrhythmic biochemical and metabolic milieu that can predispose to malignant ventricular arrhythmias.…”

Section: Figure 1) a Sustained Polymorphic Ventricular Tachycardia Rementioning

confidence: 99%

Cardiac arrest caused by undersensing of a temporary epicardial pacemaker

Chemello

Subramanian

Nanthakumar

2010

Canadian Journal of Cardiology

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T he R-on-T phenomenon is a well-known entity that predisposes to dangerous arrhythmias. Although it is widely quoted in the literature, there are only a few illustrated cases reported. Some of these are related to undersensing of temporary pacing wires (1,2). Epicardial pacemaker wire insertion has been a standard practice after cardiothoracic surgery in most world centres. Despite the lack of systematic information, the rate of major complications associated with such wires is considered low. We report three polymorphic ventricular tachycardia episodes related to the R-on-T phenomenon caused by undersensing of the pacing wire in a single patient. Potential contributing factors associated with such complications, as well as preventive measures, are discussed. Case PresentationA 65-year-old man with hypertension, chronic obstructive pulmonary disease and peripheral vascular disease underwent coronary artery bypass surgery. Temporary epicardial pacing wires were left in place for backup pacing. During the early postoperative period, he developed significant sinus bradycardia requiring pacing support. His subsequent postoperative course was uneventful and after 24 h, he was transferred out of the intensive care unit with backup ventricular pacing at 50 beats/min in VVI mode.In the postoperative unit, the patient had sudden cardiac arrest and was successfully resuscitated without cardioversion. He was intubated and transferred back to the intensive care unit. Telemetry recordings during the cardiac arrest revealed an episode of sustained polymorphic ventricular tachycardia caused by the R-on-T wave phenomenon ( Figure 1A) triggered by asynchronous pacing from the temporary pacemaker. The corrected QT interval before the event was 440 ms. The patient's potassium and magnesium levels before the episode were 3.8 mmol/L and 0.6 mmol/L, respectively. The telemetry recording also revealed two other episodes of nonsustained ventricular tachycardia ( Figures 1B and 1C) immediately before the cardiac arrest episode, also caused by asynchronous pacing stimuli on the T waves. On evaluation of the pacemaker, there was evidence of increased pacing threshold and intermittent loss of R wave sensing. The temporary pacemaker unit was turned off. DisCussionThe R-on-T phenomenon leading to polymorphic ventricular tachycardia and cardiac arrest, occurring due to intermittent loss of sensing by the temporary pacing wire, has been reported previously (1,2). However, the present report is the first to show such a dangerous complication occurring consistently over a short period of The R-on-T phenomenon is a well-known entity that predisposes to dangerous arrhythmias. Typically, a premature ventricular complex occurring at the critical time during the T wave of the preceding beat precipitates ventricular tachycardia and fibrillation. This phenomenon can occur not only in asynchronous ventricular pacemakers, but also in synchronous pacemakers, if loss of sensing of the intrinsic rhythm becomes evident. A patient who was fitted with a temp...

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Natural History and Predictors of Temporary Epicardial Pacemaker Wire Function in Patients after Open Heart Surgery

Cited by 42 publications

References 13 publications

Predictors of temporary epicardial pacing wires use after valve surgery

Predictors of temporary epicardial pacing wires use after valve surgery

Entraînement électrosystolique épicardique temporaire post-chirurgie cardiaque : modalités pratiques

Cardiac arrest caused by undersensing of a temporary epicardial pacemaker

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