Epicardial Pacing Wires Research Articles

Necessity of Temporary Epicardial Pacing Wires After Surgery for Congenital Heart Disease

Temporary epicardial pacing wires are commonly placed in patients undergoing surgery for congenital heart disease. Though often helpful, these wires are not without risk. We aimed to identify characteristics that would obviate placement of temporary epicardial pacing wires in this patient population. A prospective observational study was performed on patients admitted to the pediatric intensive care unit after surgery for congenital heart disease between October 2011 and October 2012. Logistic regression analysis was performed to identify independent predictors of patients in whom wires were not helpful postoperatively. Wires were placed in 213 of 249 patients. Wires were helpful in 50 patients; 23 for diagnostic purposes only, 17 for therapeutic purposes only, and 10 for both. On logistic regression analysis, absence of intraoperative arrhythmias (p < 0.01), lower arteriovenous O2difference (p < 0.01), and shorter duration of cardiopulmonary bypass (p= 0.050) were significant predictors of patients in whom wires were not helpful postoperatively. Further, the predicted probability based on logistic regression model using these 3 variables correctly identified 93% of patients who did notneed pacing wires. Four complications (1.9%) related to wires occurred, including 1 episode of life-threatening bleeding that was found, during emergent exploration, to be due to atrial perforation at the wire insertion site. Temporary epicardial pacing wires are not necessary in many patients recovering from surgery for congenital heart disease. A conservative approach to their use may therefore be warranted.

Transmyocardial Migration of a Temporary Epicardial Pacing Wire

Transmyocardial migration of a retained temporary epicardial pacing wire has been rarely reported in adult patients after heart surgery. We present the case of a child in whom a temporary epicardial pacing wire was discovered incidentally in the right ventricular outflow tract one year after surgical repair of congenital heart disease. The pacing wire was subsequently extracted using the snare method during cardiac catheterization. Clinicians caring for patients after congenital heart surgery should be aware of this uncommon though potentially life-threatening complication.

Predictors of temporary epicardial pacing wires use after valve surgery

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.

Migrated Abandoned Epicardial Pacing Wire Resulting in a Breast Abscess

Migrated Abandoned Epicardial Pacing Wire Resulting in a Breast Abscess

Anaesthetic management of a premature low-birth-weight neonate with congenital complete heart block for implantation of temporary epicardial pacing wires

The optimal anaesthetic management of neonates with complete congenital heart block (CCHB) is unknown, as there is a low incidence of such cases. Neonates with CCHB often require surgery for the initiation of electronic pacing. In addition to the challenges of anaesthetising a neonate, this procedure is risky due to the potential for hypotension, arrhythmias and cardiac arrest. We herein present the case of a premature low-birth-weight neonate with antibody-related CCHB and normal heart structure who underwent anaesthesia and surgery for epicardial pacing wire insertion on Day 1 of life. We also compare our patient's anaesthetic conduct and outcome with similar previously reported cases.

Indications for postoperative (transthoracic) epicardial pacing

Coronary heart disease remains one of the biggest killers in the UK today. In 2012 over 20 000 patients benefitted from cardiac bypass operations, some inevitably experiencing epicardial pacing wires as routine care. It is imperative that nurses caring for these patients have knowledge of caring for patients with epicardial pacing wires. This article provides a general introduction to epicardial pacing, including nursing care and some of the controversies surrounding this area.

Aortic valve replacement through J-shaped partial upper sternotomy.

The introduction of minimally invasive techniques in general surgery, in the late 1980s, influenced cardiac surgery as well. This led to the emergence of several minimal access approaches for aortic valve replacement (AVR). Currently, the upper partial sternotomy with unilateral J-shaped extension to the right through the fourth intercostal space is the most popular minimal access approach. This approach offers the comfort factor of sternotomy, improved cosmetic result, preserved respiratory mechanics, and last but not the least cost saving as no new equipment is required. On the other hand, inability to visualize the whole heart, adequately de-air the left heart, and failure to apply epicardial pacing wires are some of the perceived disadvantages of this approach. This article provides a comprehensive review of the indications, contraindications, technical aspects, outcomes, advantages and disadvantages of AVR through J-shaped partial upper sternotomy.

¿Es necesario el implante de marcapasos epicárdicos transitorios en cirugía de revascularización miocárdica?

The safety and efficacy of temporary epicardial pacing wires have been accepted and their use is common after cardiac procedures. Complications related after wire removal are unusual but it can be serious including bleeding, tamponade and death.We report an unusual case of a 48-year-old-male who underwent to a coronary artery bypass grafting procedure. The early postoperative was uneventful and he was weaned off mechanical ventilation after three hours. No use of inotropic support and blood products was required. Any arrhyhtmia was detected. As per institutional protocol, drainage tubes and epicardial pacing wires were removed after 48hours. Within 5minutes of pacing wires removal he became haemodynamically unstable. Echocardiography was performed and showed a pericardial collection compressing right ventricle with displacement of the interventricular septum in the early diastole. He was emergently reopened and an active bleeding from the pacing wires implant area was confirmed. The patient made a good recovery and he was discharged home.Temporary epicardial pacing wires implantation is overused and we should limit it to a selected patient population. Preoperative arrhythmia, antiarrhythmic therapy and diabetes mellitus have been identified as factors related to postoperative pacing.The temporary epicardial pacing wires use is lower in off-pump coronary artery bypass grafting patients.

Epicardial pacing wires, a five year, single centre experience

Results On implantation the mean threshold of all the leads was 1.1+/-0.8V at a mean pulse width of 0.5+/-0.7ms. The mean impedance of the leads was 673.4+/-268.1 OH. There was no difference in the implant data between unipolar and bipolar or steroid eluting and non-steroid eluting leads. There was a significantly lower pacing threshold in the steroid eluting leads at latest follow up (p=0.031). Similarly the pacing thresholds were lower in the bipolar leads when compared to the unipolar leads (p=0.026). There was no difference in impedance.

Feasibility of customised unipolar conversion using bipolar temporary pacing wires in patients after surgical repair of congenital heart disease

Temporary pacing wires play a crucial role in the diagnosis and therapy of post-operative arrhythmia after surgery for congenital heart disease. At present, bipolar pacing wires are used in most institutions. In case of functional failure of these wires, a unipolar mode of stimulation and sensing should be theoretically possible as a rescue procedure. We tested the feasibility of the customised unipolar mode in 18 post-operative patients with congenital heart disease (age 9.2 ± 13.9 months, weight 6.3 ± 3.8 kg, and cardiopulmonary bypass time 70 ± 29 minutes). As there are two possible unipolar configurations, there are twice the number of testing parameters; of those, we compared sensing (mV) and pacing thresholds (V at 0.5 ms). Atrial sensing was significantly better in the unipolar modes (p < 0.001, p < 0.003). The ventricular unipolar sensing did not differ significantly in the "better" of the two possible configurations from the bipolar values (p = 0.363). For the unipolar pacing thresholds, only the "better" unipolar configuration did not differ significantly from the bipolar measurements (atrial: p = 0.058, ventricular: p = 0.138). There was no exit block or undersensing. The results demonstrate that unipolar stimulation and sensing using bipolar epicardial temporary pacing wires is feasible. In the case of failure of bipolar temporary pacing wires, this modality represents an easy rescue measure that in such cases should always be considered.

Intraaortic Migration of an Epicardial Pacing Wire: Percutaneous Extraction

Infrequent but serious complications have been described in association with temporary epicardial pacing wires. We describe the case of an intraaortic migration of an infected retained atrial temporary epicardial pacing wire and the transfemoral percutaneous interventional approach for its extraction.

Case of the Month #181: Iatrogenic Colon Perforation During Epicardial Pacing Wire Placement

Case of the Month #181: Iatrogenic Colon Perforation During Epicardial Pacing Wire Placement

EComment. Retained temporary epicardial pacing wires in cardiac surgery

We read with great interest the best evidence topic by Shaikhrezai and colleagues regarding retained temporary epicardial pacing wires (TEPWs) in cardiac surgery and we agree with their recommendations [1]. TEPWs are used routinely in the postoperative period following cardiac surgery and its use is associated with low morbidity and mortality [1, 2]. Significant predictors for pacing in the postoperative period include diabetes mellitus, preoperative arrhythmias and need for pacing during the operation (coming off cardiopulmonary bypass, etc). If patients with these risk factors were excluded, only 2.6% patients of coronary artery bypass graft (CABG) surgery will require pacing [2]. The incidence of major complications following TEPWs removal is 0.04% [2]. The risk of complications is higher in redo cardiac surgery and anti-coagulated patients [2]. Patients' vital signs should be monitored following the removal of TEPWs to allow early and prompt identification of related potential complications [2]. Retained TEPWs rarely cause problems [1, 2]. Chung and Smith have reported on two cases of delayed presentation of anterior mediastinal foreign body reaction secondary to retained TEPWs [3]. The first case was related to a 59-year-old man who had CABG and six years later, presented with an abscess in the lower third of his sternotomy incision, which was treated with debridement and removal of the underlying sternal wires. Even though the wound had healed well, a mid-sternal swelling combined with right subcostal sinus eventually developed [2]. A computed tomography scan showed a retrosternal, ill-defined area of soft tissue extending into the superior mediastinum containing the retained TEPWs. The patient was treated successfully with opening of the sinus, removal of the TEPWs and remaining sternal wires with healing of the wounds by secondary intention [3]. The second case was quite similar to the first one and was related to a 64-year old woman who had CABG and five years later was presented with abscess in the lower third of the sternotomy scar. The same approach with the first case was used successfully after confirmation with a CT scan of the retrosternal collection associated with retained TEPWs [2]. Lyons et al., in 1986, have reported on four cases with infection and bacteraemia due to retained TEPWs [3]. The authors illustrated that the failure of removal of the TEPWs should be considered as a real surgical complication and not just a trivial event [4]. In conclusion, because it is suggested that off-pump CABG may be associated with reduced requirement of TEPWs, its routine insertion might be considered carefully [2, 5]. In the case of retained TEPWs, the patient has to be aware of any related potential complication, the incident has to be documented in the patient records and its inclusion in the differential diagnosis of any relevant postoperative complication is of paramount importance [1]. Conflict of interest: none declared

Retroaortic abscess: an unusual complication of a retained epicardial pacing wire

Infectious complications related to retained temporary epicardial pacing wires are rare. We report a case of a focal retroaortic abscess in association with retained pacing wires that became manifest 3 years after surgery for tricuspid valve endocarditis.

Optimized temporary bi-ventricular pacing improves haemodynamic function after on-pump cardiac surgery in patients with severe left ventricular systolic dysfunction: a two-centre randomized control trial

OBJECTIVESOptimized temporary bi-ventricular (BiV) pacing may benefit heart failure patients after on-pump cardiac surgery compared with conventional dual-chamber right ventricular (RV) pacing. An improvement in haemodynamic function with BiV pacing may reduce the duration of ‘Level 3’ intensive care.METHODSThirty-eight patients in sinus rhythm, ejection fraction ≤35%, undergoing on-pump surgical revascularization, valve surgery or both were enrolled in this study. Before closing the sternum, temporary epicardial pacing wires were attached to the right atrium, RV outflow tract and basal posterolateral wall of the left ventricle. Patients were randomly assigned to postoperative BiV pacing with the optimization of the atrio- (AV) and inter-ventricular (VV) pacing intervals (Group 1) or conventional dual-chamber right AV pacing (Group 2). The primary end-point was the duration of ‘Level 3’ intensive care. Secondary end-points included cardiac output which was measured by thermodiluation at admission to the intensive care unit and at 6 and 18 h later, in five different pacing modes.RESULTSThe duration of ‘Level 3’ care was similar between groups (40 ± 35 vs 54 ± 63 h; Group 1 vs 2; P = 0.43). Cardiac output was similar in all pacing modes at baseline. At 18 h, cardiac output with BiV pacing (5.8 l/min) was 7% higher than atrial inhibited (5.4 l/min) and 9% higher than dual-chamber RV pacing (5.3 l/min; P = 0.02 and 0.001, respectively). Optimization of the VV interval produced a further 4% increase in cardiac output compared with baseline settings (P = 0.005).CONCLUSIONSPostoperative haemodynamic function may be enhanced by temporary BiV pacing of high-risk patients after on-pump cardiac surgery.

Myocardial Infarction Due to a Retained Epicardial Pacing Wire

A 20-year-old man with a temporary epicardial pacing wire retained after infant repair of an atrioventricular septal defect presented with cardiopulmonary arrest. After resuscitation with extracorporeal membranous oxygenation, a coronary angiogram demonstrated a retained epicardial pacing wire compressing the left anterior descending artery and obtuse marginals. Owing to poor prognostic findings on a computed tomography scan of his head, he was terminally withdrawn from mechanical support. This case demonstrates a potential devastating complication of a retained temporary epicardial pacing wire.

Is it safe to cut pacing wires flush with the skin instead of removing them?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is safe to cut the temporary epicardial pacing wires (TEPWs) flush with the patient's skin surface prior to discharge. Altogether 105 relevant papers were identified of which 13 case reports represented the best evidence to answer the question. The author, journal, date, country of publication, complications, the culprit TEPW and relevant outcomes are tabulated. All case reports demonstrated a wide spectrum of complications. Complications from a retained TEPW mainly arise after a long dormant period. A recent case report has demonstrated the herniation of intra-abdominal contents through a diaphragmatic defect created by the abandoned epicardial pacing wires after a few decades. In multiple case reports, the migration of TEPW was the culprit of serious complications. In two case reports, the TEPWs attached to the right chambers of the heart had migrated to the pulmonary artery via the right atrium and then the right ventricle. In one case report, a similar migration of the right ventricular TEPW to the right ventricular outflow track was observed. The TEPW migration was not limited to the right side of the heart, as in one case report the right atrial TEPW had migrated to the right carotid artery via the ascending aorta. A distant extravascular migration of TEPWs to the skin surface and intraperitoneal and pelvic cavities has also been reported. Retained TEPWs have also been reported to inflict complications locally. One case report has shown a large right-sided para-cardiac mass caused by a right atrial TEPW. In two other case reports, the bronchocutaneous fistula, lobar consolidation and bronchiectasis were the manifestations of a retained TEPW. We conclude that the retention of TEPW after cardiac surgery is not necessarily safe and may cause severe complications. We recommend that TEPWs should be completely removed when possible. If TEPWs are retained, this should be appropriately documented and the surgeon should be mindful of this when the patient presents with complications postoperatively.

Aortic Bleeding One Week after Removal of an Intraoperative Epicardial Temporary Pacing Wire

A 56-year-old man had left nephrectomy and resection of a cavoatrial tumor thrombus under a cardiopulmonary bypass assist for left renal cell carcinoma. An intraoperative bipolar temporary epicardial atrial pacing wire was removed on postoperative day 8. The patient collapsed on postoperative day 15. Emergent transthoracic echocardiography and computed tomography scanning with contrast media detected cardiac tamponade. The three-dimensional volume-rendering images from the multislice computed tomography scan demonstrated bleeding from the aortic root. Upon emergency operation, active arterial bleeding from the aortic root distal to the sites of cannulation and cardioplegia was confirmed, and hemostasis with sutures was completed. It is well known that the intraoperative temporary epicardial pacing wire can cause bleeding or arrhythmia, especially when the wire is being removed. However, bleeding usually occurs from the inserted epicardial point of the pacing wire soon after removal of the wire. To our knowledge, this late bleeding complication of the pacing wire is a previously unreported serious iatrogenic complication after cardiac surgery.

Colonic Injury From Temporary Epicardial Pacing Wires

A 72-year-old man who had undergone a three-vessel coronary artery bypass grafting, aortic valve replacement, and tricuspid valve repair became comatose 1 week after the procedure. Signs of intraabdominal sepsis developed 6 days later, leading to laparotomy on his 12th postoperative day. The Intraoperative finding was a perforating injury to the transverse colon caused by the ventricular temporary pacing wires. A defunctioning double-barreled transverse colostomy was performed, after which the patient started to recover. He was discharged home 2 weeks later.

Predictors for use of temporary epicardial pacing wires after pediatric cardiac surgery

The objectives of this study were (1) to determine the use of temporary epicardial pacing wires to diagnose and treat early postoperative arrhythmias in pediatric cardiac surgical patients and (2) to determine the predictive factors for the need of pacing wires for diagnostic or therapeutic purposes. We collected preoperative, intraoperative, and postoperative data in a prospective, observational format from patients undergoing pediatric cardiac surgery between August 2010 and January 2011 at a single academic children's hospital. A total of 157 patients met the inclusion criteria during the study period. Of these 157 patients, pacing wires were placed in 127 (81%). Pacing wires were used in 25 patients (19.6%) for diagnostic purposes, 26 patients (20.4%) for therapeutic purposes, 15 patients (11.8%) for both diagnostic and therapeutic purposes, and 36 patients (28.3%) for diagnostic or therapeutic purposes. Need for cardioversion in the operating room, presence of 2 or more intracardiac catheters, severely reduced ventricular ejection fraction, and elevated serum lactate level at the time of operating room discharge were found to be independent predictors for the use of pacing wires. The only complication noted in the cohort was a skin infection at a pacing wire insertion site in 1 patient. A permanent pacemaker was required in 8 (6.2%) of all patients with temporary pacing wires. Our data support the use of temporary epicardial pacing wires in approximately 30% of children after congenital heart surgery. We found the need for cardioversion in the operating room, presence of 2 or more intracardiac catheters, severely reduced ventricular ejection fraction, and high serum lactate level at the time of discharge from the operating room to be independent predictors of the use of pacing wires in the early postoperative period.