Permanent Cardiac Pacing Research Articles

Parameters associated with one-year mortality and in-hospital adverse events in patients after emergency pacemaker implantation.

Permanent cardiac pacing is the treatment of choice for severe and symptomatic bradycardia. Patients undergoing emergency pacemaker implantation are stabilised earlier by the insertion of a temporary emergency pacing lead, and they experience more comorbidities than with planned admissions. To identify the parameters associated with one-year mortality and in-hospital adverse events after emergency permanent pacemaker implantation. This retrospective study analyses data from 131 consecutive emergency pacemaker implantations performed within a single centre. Cox regression analysis revealed the independent predictors of death to be: use of a temporary transvenous pacing lead (TTPL) (HR = 2.82, 95% CI 1.21-6.58, p = 0.02), age ≥ 78 years (OR = 3.01, 95% CI 1.22-7.42, p = 0.02), longer baseline QRS duration (HR = 1.02, 95% CI 1.00-1.03, p = 0.03), and history of myocardial infarction (MI) (HR = 2.43, 95% CI 1.04-5.68, p = 0.04). Twenty-six patients experienced in-hospital adverse events, such as: death (n = 6), cardiac arrest (n = 3), surgical complications (lead dislocation: n = 4, haematoma: n = 4, microperforation: n = 2), pneumonia or respiratory tract disease (n = 7), wound infection treated with antibiotics (n = 1), and subsequent MI following pacemaker implantation (n = 2). Multivariate logistic regression analysis showed that independent parameters associated with in-hospital adverse events were history of MI (OR = 5.01, 95% CI 1.88-13.3, p = 0.001) and stroke (OR = 3.51, 95% CI 1.16-10.55, p = 0.03). Our results suggest that the most serious risk factors of one-year mortality related to the use of TTPL are: age ≥ 78 years, longer baseline QRS duration, and history of MI. The independent parameters associated with in-hospital adverse events were the presence of a history of MI and stroke.

Venous Stenosis and Occlusion in the Presence of Endocardial Leads.

Venous stenosis and occlusion in the presence of endocardial leads constitute one of the complications of permanent cardiac pacing either by pacemaker, implantable cardioverter-defibrillator or cardiac resynchronization therapy. The aim of this study was to assess the incidence of stenosis and occlusions and determine the risk factors in patients with endocardial leads in a prospective single-center study. Two hundred eighty consecutive patients aged 25-95 years (male 68.8%) were included. A contrast venography examination of the ipsilateral access vein was performed. The whole study population was divided into 2 groups, based on the presence (group I) or absence (group II) of endocardial leads. Venous stenosis/occlusion was identified in 51 patients (37.5%) in group I and in 3 patients (3.6%) in group II; p < 0.0001. The lead presence most highly correlated with venous complications (OR = 4.172; p < 0.001). In patients with endocardial leads divided into I A and I B according to venous patency diabetes mellitus was proved in multivariate analysis to be the only protective factor against the development of venous stenosis/occlusion (OR = 0.473; p = 0.010). The presence of endocardial leads is a predisposing factor for venous stenosis/occlusion and increases the risk 4-fold. The venous lesions in the presence of endocardial leads are less frequent among patients with diabetes mellitus.

Managing heart block after transcatheter aortic valve implantation: from monitoring to device selection and pacemaker indications.

The introduction of the so-called newer-generation transcatheter aortic valve implantation (TAVI) devices has led to a dramatic reduction in the incidence of complications associated with the procedure. However, preliminary data suggest that conduction abnormalities (particularly new-onset atrioventricular block and left bundle branch block) remain a frequent complication post TAVI. Although inconsistencies across studies are apparent, new-onset conduction abnormalities post TAVI may be associated with higher incidences of mortality, sudden cardiac death and left ventricular dysfunction. Strategies intended both to reduce the risk and to improve the management of such complications are clearly warranted. In fact, the indication and timing of permanent pacemaker implantation are frequently individualised according to centre and/or operator preference. Currently, studies assessing the impact of these complications and the optimal indications for permanent cardiac pacing are underway. In this article, we review the data available on the incidence and impact of conduction disturbances following TAVI, and propose a strategy for the management of such complications.

Leadless Cardiac Pacemakers: Pacing Paradigm Change.

Traditional transvenous approach for permanent cardiac pacing can be associated with significant acute and chronic complications related partly to either the insertion of transvenous lead or subcutaneous placement of pacemaker device. We summarize the current status of a novel self-contained leadless cardiac pacemaker in the first-in-human and subsequent series of feasibility studies in patients indicated for ventricular rate-responsive pacing (VVI). Using a femoral venous approach, the device is implanted at the right ventricular apical septum region. We describe the technical and clinical characterization of this innovative technology. Two different systems of leadless pacemakers are currently implanted to the patients. Up to now, the electrical parameters, such as pacing thresholds, sensing parameters, and pacing impedances, either improved or remained stable within the accepted range. In this chapter, we also discuss the potential benefit for the future, but in summary, all available data demonstrate the feasibility of leadless cardiac pacing.

Three-dimensional binding sites volume assessment during cardiac pacing lead extraction

Background/objectivesBinding sites are the principal cause of failed lead removal and complications, and are not directly visualized by fluoroscopy. We aimed to assess binding sites between permanent cardiac pacing leads and cardiovascular structures using CartoSound™ three-dimensional (3D) imaging technology (Biosense Webster Inc., Diamond Bar, CA) during transvenous lead extraction, and compared outcomes to standard approach. MethodsWe recruited 291 patients undergoing percutaneous lead extraction, and 3D CartoSound anatomical mapping of the superior vena cava, right atrium (RA), coronary sinus, right ventricle (RV), pacing leads, and binding sites before, during, and after lead removal was randomly performed in 46 of them (38 men; mean age 73.7±10.5years; 1.96 leads/patient; mean time-from-implant of 62.7±51.8months) using a 10-Fr 3D SoundStar™ catheter and integrated into the Carto® mapping system. ResultsCartoSound was able to detect more intracardiac binding sites compared to fluoroscopy (RA 17.4% vs. 4.3%, p=0.04; RV 43.5% vs. 21.7%, p=0.04), but was unable to assess the subclavian/innominate veins. Binding sites volume correlated positively with time-from-implant (r=0.38, p<0.05), and powered-sheath use (r=0.39, p<0.05), and negatively with procedural success (r=−0.37, p<0.05). When compared to standard approach, CartoSound use was characterized by a significantly lower mean procedure time (p=0.0001), major complications (p=0.03), and greater procedure success rates (p=0.03). ConclusionsReal-time 3D binding sites assessment is feasible and improves transvenous lead extraction outcomes. Its role as a complementary information requires extensive validation, and might be beneficial for a tailored strategy.

Routine use of biventricular pacing is not warranted for patients with heart block.

Ventricular pacing can be lifesaving for patients with complete atrioventricular block (AVB). Since the introduction of permanent transvenous cardiac pacing >40 years ago, the right ventricular (RV) apex has been the preferred site for ventricular stimulation. This location provides good fixation and low capture thresholds. However, RV apical pacing may induce cardiac dyssynchrony. Hence, it has been suggested that all patients with symptomatic AVB (regardless of current indication for biventricular pacing), with anticipated high RV pacing burden, should receive preventive biventricular pacing. In this article, we review the physiological effects of RV pacing, data from observational studies (Table I in the Data Supplement),1–6 and available randomized trials comparing biventricular versus RV pacing (Table).7–16 View this table: Table. Randomized Controlled Studies Comparing Right Ventricular and Biventricular Pacing Response by Fang et al on p 738 Since the initial report of the use of endocardial pacing to treat complete AVB by Furman and Schwedel in 195917, pacemakers have evolved dramatically into complex devices with the ability to sequentially pace the atrium and both ventricles. Between 1993 and 2009, 2.9 million patients received a permanent pacemaker in the United States.18 During this time, overall pacemaker use increased by 55.6%. However, although the use of dual chamber (DDD) pacemakers increased by at least 40%, the use of single-chamber ventricular (VVI) pacemakers decreased ≈50%,18 despite the evidence from large pacing trials19–21 indicating no major differences in outcomes between single and dual chamber pacing modes. In fact, by 2009, DDD pacemakers accounted for 82% of all implants (VVI for only 14%).18 These statistics speak loudly about the impact of technology on daily clinical practice. A similar quandary now exists with regards to biventricular pacing. We suggest that the global utilization of biventricular pacing for all …

Przypadek niedrożności żyły bezimiennej — wpływ na wybór postępowania zabiegowego w stałej elektroterapii serca

Successful transvenous insertion of cardiac pacing leads during pacemaker implantation is contingent on the patency of consecutive vessels. Vessel obstruction can be detected during either first-time or subsequent procedures associated with the need to introduce additional pacing leads. Venous thrombosis is the most common cause for vessel occlusion, and the main occlusion site along the venous route used for cardiac lead insertion is the subclavian vein, in contrast to the innominate vein or the superior vena cava, whose occlusion rates are much lower. The patient presented here developed venous thrombosis in the left brachiocephalic vein (BCV) also known as the innominate vein 5 years after a first-time permanent cardiac pacing system implantation. Contrast-enhanced vascular imaging conducted during a subsequent procedure intended to introduce a new lead revealed the location and extent of BCV occlusion. Out of 2,258 procedures requiring cardiac lead insertion and performed within a 5-year period (2010–2014) at the Clinic (including 68 cases of adding a lead to the existing device) this was the only case of BCV occlusion of this aetiology. Literature reports on BCV emphasize the uncommonness of this type of occlusion and discuss its effect on the course of the procedure.

Permanent cardiac pacing in a patient with persistent left superior vena cava and concomitant agenesis of the right-sided superior vena cava

Persistent left superior vena cava (PLSVC) can be incidentally detected during pacemaker implantation from the left pectoral side. Optimal site pacing is technically difficult, and lead stability of the right ventricle (RV) can lead to such a situation. We describe a case of successful single-chamber pacemaker implantation in a 76-year-old woman with a PLSVC and concomitant agenesis of the right-sided superior vena cava, after failed attempts with the conventional procedure. The pacemaker had been working well after 12 months of follow-up.

Importance of the heart failure mechanisms during permanent single-chamber cardiac pacing for optimization of rate-adaptive mode

Importance of the heart failure mechanisms during permanent single-chamber cardiac pacing for optimization of rate-adaptive mode

Permanent pacing in patients without upper limb venous access: a review of current techniques

Permanent transvenous cardiac pacing is usually accomplished through the upper limb veins. When these are occluded, several other vascular access options exist which include the internal jugular, external jugular, femoral...

Complications of permanent cardiac pacing in patients with persistent left superior vena cava

Persistent left superior vena cava (PLSVC) is present in about 0.3-0.5% of the general population and in about 12% of patients with other abnormalities. This congenital anomaly is usually asymptomatic and does not cause any physiological problems. However, it may become a significant problem in multiple clinical situations. Various complications related to PLVSC are encountered in anesthesiological, nephrological, oncological and cardiological procedures. The presence of PLSVC is usually incidentally detected during placement of pacemaker (PM), implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy (CRT) leads. Technical difficulties during lead positioning (especially ventricular leads) are commonly known and often described in the literature. The purpose of the present study was to evaluate the specific methods used for implantation of increasingly complicated pacing systems, finding an optimal strategy in patients with PLSVC, especially with electrotherapy complications. We performed a single-center retrospective analysis of 11 patients (7 women and 4 men, mean age 60.4 ± 13 years) with PLSVC hospitalized in single Cardiology Department between 2000 and 2012. The clinical characteristic, indications for PM/ICD/CRT implantation, technique of implantation and complications were evaluated. In PLSVC patients, different indications for pacing or resynchronization therapy were represented: sick sinus syndrome (SSS) in 4 patients, 3rd degree atrio-ventricular (AV) block in 4 patients, dilated cardiomyopathy with left bundle branch block in 2 patients, dilated cardiomyopathy and non-sustained ventricular tachycardia episodes in 1 patient. In patients no. 1, 3, 4 and 10 the complications necessitated the change of leads or type of pacing. Transvenous lead extraction was successfully performed in patient no. 1 and 10 with re-implantation of new leads via PLSVC in patient no. 1 and via right superior vena cava in patient no. 10. Patient no. 3 received an additional ventricular lead via PLSVC because of 2nd degree AV block (formerly atrial lead implanted due to SSS). In patient no. 4 with left atrial pacing (lead in coronary sinus), prosthetic mitral valve replacement was combined with epicardial ventricular lead placement. Patients no. 2 and 7 received a CRT device, without technical problems in patient no. 7, whereas in patient no. 2 due to difficulties with left ventricular lead positioning a hybrid approach to epicardial lead pacing was used. In patient no. 8 an ICD was implanted with difficulty in placing defibrillator lead. Patient no. 5 received 2 atrial leads via PLSVC with successful biatrial pacing; patient no. 6 with the necessity of DDD pacing had a (ventricular) lead for left atrial pacing and a typical right ventricular lead. In patients no. 9 and 11 typical DDD pacing was used with contralateral placement of the leads due to anatomical and technical differences. After 12 years of follow-up the survival is 90.9%. Late electrotherapy complications have developed only in patient no. 8 (problems with the defibrillator lead). Patients with PLSVC are a very heterogeneous group with different indications for pacing, therefore individualization of therapy is required. Technical complications connected with pacing of the right heart chambers are commonly known, hence transvenous left atrial or left ventricular lead implantation should be attempted. In case of difficulties in transvenous positioning of the lead, a hybrid or isolated cardiac surgery technique should be considered. Because of the increasing number of electrotherapy complications, these problems are also present in PLSVC patients. Transvenous lead extraction with re-implantation of a pacing system has not been reported yet. For this reason a thorough evaluation of the venous system is required in PLSVC patients before intervention.

Cardiology registrars and permanent pacemaker complication rates in a district general hospital—safety and service implications

Permanent cardiac pacing in the district general hospital (DGH) was endorsed by the British cardiovascular society in 1987, and by 1992 a third of DGHs provided this service.1,2 More than two decades have passed and the rates at which permanent pacemakers (PPM) are being implanted have risen substantially. Implant rates in England have increased by approximately 4% per year since 2000 to 525 PPM per million persons in 2011, but our implant rates are still much lower than those of several of our European neighbours.3 An ageing population, greater recognition of pacing indications, and the expansion of the service for local convenience are some of the reasons for the rising implantation rates. With such increasing numbers, and newer devices and leads, it is important to get an updated perspective on the complication rates so that patients are given the correct information when they are consented. Unfortunately, beyond the data published over ten years ago from the large centre trials,4–8 there is only one recently published report from a UK DGH.9 In addition to this, the current structure of specialty training in cardiology leads to most junior registrars acquiring their first experience of device implantation in the DGH. There is evidence that suggests that inexperience is positively correlated with complication rates in the short and long term.10 Yet, there are no published data demonstrating the impact that registrar training has on patient safety and service provision in the DGH. This prospective study, carried out over four and a half years, provides an update on the complication rates of pacemaker implantation in the DGH, and we compare this with other studies in the literature. This study also adds novel prospectively collected data to the literature on registrar complication rates and provides information on the impact that current training arrangements have on service provision.

Temporary pacing: clinical indications and techniques

Patients suffering bradycardia and haemodynamic compromise may require implantation of a temporary pacemaker as a bridge to permanent cardiac pacing. This article provides an insight into such temporary pacing, the indications for pacing, the types of pacing most commonly used and some of the key issues surrounding this intervention.

The effect of dual-chamber closed-loop stimulation on syncope recurrence in healthy patients with tilt-induced vasovagal cardioinhibitory syncope: a prospective, randomised, single-blind, crossover study

BackgroundThe closed-loop stimulation (CLS) pacemaker algorithm is a system that permanently monitors the contractile state of the myocardium and converts the intrinsic information into rate regulation. The role that the...

Complications of pacemaker therapy in adults with congenital heart disease: A multicenter study

This study aims to investigate indications and complications of permanent cardiac pacing in adults with congenital heart disease (CHD). Two-hundred and seventy-four CHD patients were identified who underwent permanent pacemaker implantation between 1972 and 2009. The indication for pacing was acquired sinus node or AV node conduction disease (63%), sinus node or AV node conduction disease after cardiac surgery (28%), and drug/arrhythmia-related indications (9%). Patients with complex CHD received a pacemaker at younger age (23 versus 31 years, p<0.0001) and more often received an epicardial pacing system (51% versus 23%, p<0.0001) compared to those with simple or moderate CHD. Twenty-nine patients (10.6%) had a periprocedural complication during the primary pacemaker implantation (general population: 5.2%). The most common acute complications were lead dysfunction (4.0%), bleeding (2.6%), pocket infection (1.5%) and pneumothorax (1.5%). During a median follow-up of 12 years, pacemaker-related complications requiring intervention occurred in 95 patients (34.6%). The most common late pacemaker-related complications included lead failure (24.8%), pacemaker dysfunction/early battery depletion (5.1%), pacemaker migration (4.7%) and erosion (4.7%). Pacemaker implantation at younger age (<18 years) was an independent predictor of late pacemaker-related complication (adjusted hazard ratio 1.68, 95% confidence interval 1.07 to 2.63, p=0.023). The risk of periprocedural complications seems higher in the CHD population compared to the general population and more than one-third of CHD patients encountered a pacemaker-related complication during long-term follow-up. This risk increases for those who receive a pacemaker at younger age.

Bradyarrhythmic syncope in a patient with Prinzmetal's variant angina: a case report

We present the case of a 46-year-old woman with Prinzmetal's angina and syncope due to severe bradyarrhythmias. Dynamic electrical changes were documented on 12-lead 24-hour electrocardiographic (ECG) monitoring. We highlight the importance of continuous ECG monitoring in making the diagnosis and the indication for permanent cardiac pacing in this case.

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Prevention of Syncope Through Permanent Cardiac Pacing in Patients With Bifascicular Block and Syncope of Unexplained Origin

Background— Syncope in patients with bifascicular block (BFB) is a common event whose causes might be difficult to assess. Methods and Results— Prevention of syncope through permanent cardiac pacing in patients with bifascicular block (PRESS) is a multicenter, prospective, randomized, single-blinded study designed to demonstrate a reduction in symptomatic events in patients with bifascicular block and syncope of undetermined origin implanted with permanent pacemaker. Device programming mode (NASPE/BPEG code) at DDD with a lower rate of 60 ppm is compared with backup pacing at DDI with a lower rate of 30 ppm. The end point consisted of (1) syncope, (2) symptomatic presyncopal episodes associated with a device intervention (ventricular pacing), and (3) symptomatic episodes associated with intermittent or permanent atrioventricular block (any degree). One hundred one patients were enrolled and randomized. Primary end point events at 2 years were observed in 23 patients, with a significant lower incidence in the study group (hazard ratio, 0.32; 95% confidence interval [CI], 0.10–0.96; P =0.042). Reduction of any symptoms, associated or not with device intervention, was superior in DDD60 compared with DDI30 (hazard ratio, 0.4; 95% confidence interval, 0.25–0.78; P =0.0053). Fourteen patients developed other rhythm diseases and met class I indication for pacing. The annual incidence of rhythm disease development was 7.4%. Conclusions— In patients with bifascicular block and syncope of undetermined origin, the use of a dual chamber pacemaker programmed to DDD60 led to a significant reduction of syncope or symptomatic events associated with a cardioinhibitory origin, compared with DDI30 programming. Symptoms associated with a new onset of rhythm disease were found in 15% of the population at 2 years.

TUGENDHAT: a pilot randomized study on effects of biventricular pacing in patients with bradycardia pacing indication and normal systolic function on heart failure, atrial fibrillation and quality of life (results of 12 month follow-up)

Since the late 1990s, a growing number of clinical studies have indicated that long-term permanent right ventricular (RV) apical pacing will induce severe complications such as development of heart failure, increased burden of atrial fibrillation leading to decreased quality of life. To investigate whether cardiac resynchronization therapy (CRT) using biventricular (BiV) pacing can prevent the development of left ventricular (LV) dysfunction, LV remodelling, worsening of the clinical status and quality of life in chronically RV paced patients with normal LV ejection fraction (EF). A total of 127 patients with Class I indication for permanent cardiac pacing and without established indication for CRT were subjected to 6 months of RV and BiV pacing in a patient-blinded, randomized crossover trial. Treatment effects of BiV pacing were evaluated for LV function, LV remodelling and clinical status. As compared with RV pacing, BiV pacing did not significantly prevent the decrease of LV function [LVEF 61.0 % (36.0; 68.0) vs 60.5 % (38.5; 67.5) in RV pacing], did not change the functional class according to the New York Heart Association [52 % in Class II vs 53.9 % in Class II in RV pacing, and 3.9 % in Class III vs 6.9 % in Class III in RV pacing], and did not present any changes in quality of life [32.5 (18.0; 80.0) vs 32.0 (21.0; 47.0) indexes in RV pacing]. BiV pacing, compared to RV pacing, did not change LV function and quality of life in patients with the absence of LV dysfunction or remodelling, standard bradycardia pacing indications in a pilot phase (12- month follow-up) of the TUGENDHAT trial. The final report will be published after 60-month follow-up termination (Tab. 5, Fig. 3, Ref. 30).

Infections secondary to pacemaker implantation : a synopsis of six cases : case report - online article

Permanent cardiac pacing is a technique whose indications have increased in the last 20 years. As with any foreign body, pacemaker implantation is associated with the risk of infection. The objective of this study was to describe the clinical, paraclinical and treatment options of infections secondary to pacemaker implantation at the Cardiology Department of the Aristide le Dantec Teaching Hospital (CHU Aristide le Dantec) in Dakar, Senegal. We conducted a retrospective study over a period of three years (from January 2005 to December 2007) during which pacemaker implantation was carried out in 107 patients. All patients with local and/or systemic signs of infection were included in our study. The prevalence of infection in patients with pacemakers was 5.6% in our series and infection occurred in three women and three men, with a mean age of 66.2 years (range 23-83). The delay time for the onset of clinical signs of infection was 6.6 months, with a range of eight days to 12 months. The clinical signs were externalisation of the pacemaker with suppuration (five cases), fever (one case) and inflammatory signs (one case). Factors favouring the occurrence of infection were co-morbidity (four cases), pre-operative length of stay (average eight days), use of temporary cardiac pacing (three cases), the number of people in the theatre (average 4.5), postoperative haematoma (one case) and repeating the surgical procedure (three cases). Staphylococcus epidermidis (two cases), Staphylococcus aureus (two cases) and Klebsiella pneumonia (one case) were the organisms isolated at the local site. Transthoracic echocardiography showed no objective signs of endocarditis. The treatment was antibiotic therapy for an average duration of 50.4 days after debridement of the infected site (six cases). We noted four recurrences at six months and one death from sepsis at 12 months. Infections secondary to pacemaker implantation are rare but serious. Their management is difficult and requires the removal of the implanted material, hence the importance of prevention of infection, or the removal and re-implantation of the pacemaker at another site in cases of infection. This is particularly important in our region where pacemakers are very expensive.