PACEMAKER IMPLANTATION

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PACEMAKER IMPLANTATION

• Alpay Celiker M.D.
• Acibadem University

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Pacing in Pediatric Congenital Heart Disease

• Advances in lead and device technology allow
  pacemaker system implantation in children and
  even in neonates
• Specific problems in children such as small
  vessel size, cardiovascular abnormalities often
  lead to implant problems.
• Physical activity and somatic growth may affect
  lead longevity in young patients

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Points of Interest

• Leads
• Endocardial, or epicardial
• Passive or active fixation
• Chamber Paced
• VVIR, DDD, or VDD

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Pros and Cons of Transvenous Leads

• Venous obstructions
• Pace related impaired ventricular function.
• Lead infections
• Lead extraction necessity
• Interaction with cardiac valves
• Impossible in some patients

• Leads generally more reliable than epicardial
  implants
• Procedure more easy
• Less thresholds
• Fast adaptation to new pacemaker systems

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Venous Occlusion 11 out of 85 (13) total venous
obstruction 10 (12) partial obstruction. Age,
body size and lead type not associated with
occlusion gt 3 years . Bar Cohen 2006
Tricuspid valve issue 27 out of 123 TR
increased. No severeTR. No change (63) or
improved (12). Berul 2008.
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An inhomogeneous and dyssynchronous electrical
activation of ventricles, leading to changes in
myocardial architecture and left ventricular
mechanical contractions. This problem is
secondary to right ventricle apical pacing via
transvenous pacing.
Karpawich P. Pace 2008
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Pediatric Pacemaker Infections

• Perioperative Infections (before discharge)
• Superficial 1,2
• Deep 0,2
• Early Pacemaker Infections (lt 60 days)
• Superficial 3,1
• Deep 1,2
• Late Pacemaker Infections
• Superficial 0,5
• Deep 0,7

• Staphylococcus species were isolated in 44
• Increased Risks
• Reintervention
• Down syndrome
• Subcutaneous ? preperitoneal pocket

Cohen et al J Thorac Cardiovasc Surg 2002 124.
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Lead Extraction in Children.Why?

• Remove the intravascular and intracardiac lead
  material
• Relieve and reconstruct the venous access for the
  new leads
• Prevent lead related infection

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Indications

• Class I
• a sepsis
• b life-threatening arrhythmia
• c life threatening condition
• d thromboembolic event caused by retained lead
• Obliteration of all useable veins
• Lead interfereres with the operation of another
  device

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Cons
Epicardial Pacing

• Implantation procedure more invasive than
  endocardial
• Surgery required
• Leads are weaker

• Pros
• Venous access not required
• Usable patients with compromised venous access
• Allows left ventricular pacing, even in small
  patients
• Dual chamber pacing in small patients

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Epicardial versus Endocardial Pacing Conclusion

• Epicardial
• lt15 kg
• Compromised venous access or a univentricular
  heart
• Pace the left ventricle
• Endocardial
• Possible implant lt15kg
• Venous occlusion
• Risks of future lead extraction
• Beware of pacing induced heart failure

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Epicardial Pacing
A substantial proportion of patients with
epicardial pacemakers do, however, require
reintervention within five years. Median
sternotomy is a risk factor
Noiseux et al. Thirty years of experience with
epicardial pacing in children. Cardiol Young 2004
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Preserved cardiac synchrony and function with
single-site left ventricular epicardial pacing
during mid-term follow-up in paediatric patients.
Tomaske M, Breithardt OA, and Bauersfeld U.
Europace 2009.
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RV PACE (N10 LV PACE (N15)
Interventricular mechanical delay (ms) 6215 1710
Septal-to-posterior wall motion delay (ms) 29484 5923
Septal-to-lateral wall delay, by TDI (ms) 5912 4019
LV mechanical delay, 2D strain (ms) Mitral valve level 15944 7231
LV mechanical delay, 2D strain (ms) Papillary muscle level 12725 6423
RV mechanical delay, 2D strain (ms) 6233 5723
RV (ms) 19742 21043
LV ejection fraction () 456 606
LV end-systolic volume index (mL) 3311 225
Aortic velocity time integral (cm) 212 264
LV Tei index 0,630,11 0,380,07
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DDD vs VDD

• VDD pacing may be an alternative for DDD pacing
  in children with normal sinus node function.
• Ovsyshcher, Rosenthal and Seiden et al. have been
  showed good results with this mode of pacing.
• Late results of this mode of pacing seems to
  encourage
• Atrial electrogram amplitude was decreased in
  children without any atrial sensing problem. Loss
  of atrial sensing can be a problem in children
  with operated congenital heart diseases.
• It may be first choice older children with
  congenital AV block and normal sinus node
  dysfunction.

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VVIR versus DDD Pacing

• VVIR Pros and Cons
• Pros One lead required, Smaller generator,
  gives satisfactory exercise tolerance, slower
  heart rates than DDD
• Cons Heart rate response is not physiological,
  loss of AVsynchrony,

• DDD Pros and Cons
• Pros Physiological heart rate response, AV
  synchrony maintained, reduced risk of atrial
  fibrillation
• Cons Two leads required, larger generator,
  faster heart rates than VVIR, pacemaker mediated
  tachycardia

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VDD Pacing

• Disadvantages
• Atrial sensing problems in postop. cases
• Relative change of atrial dipole with the growth
• Decrease of AV synchrony with time
• Lack of active fixation
• Large electrodes
• No indication in SSS
• Lack of epicardial use

• Advantages
• Single lead dual chamber sensing
• Avoid of many electrodes
• Provide AV Synchrony
• Avoid of venous thrombosis??

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Site Selective Pacing
Select Secure system steroid eluting, bipolar,
lumenless, non-retractable screw-in 4,1 F lead
(model 3830, Medtronic, Inc.), delivered through
a 8F steerable catheter (Select Site)

• Pioneereed by Karpawich.
• Implant possible to desired place
• Less material at venous system and heart
• Similar results compared to conventional systems
• Lead extraction issue?
• Long-term results?

Karpawich et al. Altered cardiac histology
following apical right ventricular pacing in
patients with congenital atrioventricular block.
Pacing Clin Electrophysiol 1999
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Conclusion

• Long term complications of pacing in childhood
  include venous occlusion, impaired ventricular
  function, lead failure, and risks of multiple
  implants and explants.
• Right ventricular apical pacing should be
  minimised where possible.
• In small infants epicardial pacing should be
  encouraged.
• Long term complications largely relate to
  problems with the leads.