Permanent pacemaker implantation in pediatric heart transplant recipients: A systematic review and evidence quality assessment

Abstract

Bradyarrhythmias are a common complication following pediatric OHT and may require permanent pacemaker implantation (PPM). The purpose of this study was to investigate the incidence, predictors, and outcomes of children undergoing PPM implantation following OHT. A PRISMA‐compliant systematic literature review was performed using the PubMed database and the Cochrane Library (end‐of‐search date: January 27, 2019). The Newcastle‐Ottawa scale and the Joanna Briggs Institute tool were used to assess the quality of cohort studies and case reports, respectively. We analyzed data from a total of 11 studies recruiting 7198 pediatric patients who underwent heart transplant. PPM implantation was performed in 1.9% (n = 137/7,198; 95% CI: 1.6‐2.2) of the patients. Most patients underwent dual‐chamber pacing (46%, 95% CI: 32.6‐59.7). Male‐to‐female ratio was 1.3:1. Mean patient age at the time of OHT was 10.1 ± 6.3. Overall, biatrial anastomosis was used in 62.2% (95% CI: 52.8‐70.6) of the patients. The bicaval technique was performed in the remaining 37.8% (95% CI: 29.4‐47.1). Sinus node dysfunction was the most frequent indication for PPM implantation (54.4%; 95% CI: 42.6‐65.7) followed by AV block (45.6%; 95% CI: 34.3‐57.3). The median time interval between OHT and PPM implantation ranged from 17 days to 12.5 years. All‐cause mortality was 27.9% (95% CI: 18.6‐39.6) during a median follow‐up of 5 years. PPM implantation is rarely required after pediatric OHT. The most common indication for pacing is sinus node dysfunction, and patients undergoing biatrial anastomosis may be more likely to require PPM.

Cardiac allograft vasculopathy and donor age affecting permanent pacemaker implantation after heart transplantation

“…The incidence of PM implantation after HT in literature varies between 2% and 24%. [1][2][3][4][5][7][8][9]19,20 Our incidence of 14% is in accordance with this. This variation can be explained by several factors such as difference in follow-up duration, inclusion of paediatric patients, average donor age, and local policy on PM indications.…”

“…Due to the fact that children are more often affected by cardiomyopathies and congenital cardiac abnormalities and not so much by ischaemic cardiomyopathy, the need for amiodarone use in these recipients is less before HT. 19 Ischaemic time during transplantation was another predictor for early PM implantation. Recently, other studies have found no relationship between ischaemic time and PM implantation, [1][2][3]5,7,9 while it has been suggested as a potential risk factor.…”

“…6 The reason why age was protective for the whole study population, but not in adults, is probably due to the paediatric recipients who needed a PM long term after HT. Although in literature the incidence of PM in children after HT is low, 19 long-term studies are missing. Young recipients mostly receive hearts from young donors, decreasing the chance of a PM early after HT.…”

Pediatric Heart Transplant: Initial Experience in a Tertiary Center in Brazil

“…Those who develop bradyarrhythmia may need temporary pacing, if they do not have an adequate chronotropic response to isoproterenol in the immediate postoperative period, or permanent pacemaker implantation, if persistent. In a meta-analysis of 7,198 pediatric heart transplant recipients, Mylonas et al [ 17 ] reported a prevalence of 1.9% (137) of that requiring permanent pacemaker implantation. Sinus node dysfunction and complete atrioventricular block were the main indications, more frequently in patients operated using the Lower-Shumway technique.…”

Impact of the operative technique on mid‐ and long‐term results following paediatric heart transplantation

“…We are aware that TVR can be caused through injury during myocardial biopsy with the bioptome passing across the tricuspid valve ring. 34,37 Therefore, it can be induced over time due to a higher frequency of endomyocardial biopsies in the context of the post-transplant monitoring. In our centre, the use of rejection monitoring with biopsy has decreased in recent years.…”