Temporary Epicardial Pacing Wires Research Articles

Bioresorbable molybdenum temporary epicardial pacing wires

Cardiac pacing with temporary epicardial pacing wires (TEPW) is used to treat rhythm disturbances after cardiac surgery. Occasionally, TEPW cannot be mechanically extracted and remain in the thorax, where they may rarely cause serious complications like migration and infection. We aim to develop bioresorbable TEPW that will dissolve over time even if postoperative removal is unsuccessful. In the present study, we demonstrate a completely bioresorbable design using molybdenum (Mo) as electric conductor and the resorbable polymers poly(D, L-lactic-co-glycolic acid) (PLGA) and polycaprolactone (PCL) for electrically insulating double-coating. We compared the pacing properties of these Mo TEPW demonstrators to conventional steel TEPW in Langendorff-perfused rat hearts and observed similar functionality. In vitro, static immersion tests in simulated body fluid for up to 28 days elucidated the degradation behaviour of uncoated Mo strands and the influence of polymer coating thereon. Degradation was considerably reduced in double-coated Mo TEPW compared to the uncoated and the PLGA-coated condition. Furthermore, we confirmed good biocompatibility of Mo degradation products in the form of low cytotoxicity in cell cultures of human cardiomyocytes and cardiac fibroblasts. Statement of significanceTemporary pacing wires are routinely implanted on the heart surface to treat rhythm disturbances in the days following cardiac surgery. Subsequently, these wires are to be removed. When removal attempts are unsuccessful, wires are cut at skin level and the remainders are left inside the chest. Retained fragments may migrate within the body or become a centre of infection. These complications may be prevented using resorbable pacing wires. We manufactured completely resorbable temporary pacing wires using molybdenum as electrical conductor and assessed their function, degradation and biological compatibility. Our study represents an important step in the development of a safer approach to the treatment of rhythm disturbances after cardiac surgery.

Abstract 15121: Bioresorbable Molybdenum Electrodes: Towards a Novel Generation of Temporary Epicardial Pacing Wires

Introduction: Cardiac pacing with temporary epicardial pacing wires (TEPW) is used to treat rhythm disturbances after cardiac surgery. Removal is recommended on day 4-7. Occasionally, TEPW cannot be mechanically extracted, have to stay in the thorax and may rarely cause serious complications like migration and infection. We aim to develop novel, bioresorbable TEPW that will dissolve over time even if postoperative removal is unsuccessful. Methods and Results: We manufactured prototypical braided molybdenum (Mo) leads (16 Mo wires of 40 μM diameter each, length 18 cm for ex-vivo, 7.5 cm for in-vivo trials) coated with the biodegradable polymers poly(lactide-co-glycolic acid) (PLGA, inner coating) and polycaprolactone (PCL, outer coating) for shaping and electrical insulation. Mo electrodes showed similar pacing and sensing properties to conventional steel electrodes (Osypka) in Langendorff-perfused rat hearts, even with somewhat lower stimulation thresholds. In artificial body fluid at 37°C, polymer-coated Mo electrodes dissolved at a rate of 1.6 ± 0.3 μg/cm 2 ·d (n=5) compared to uncoated electrodes with 30.3 ± 0.8 μg/cm 2 ·d (n = 4, p < 0.001). Assessing apoptosis and necrosis in human cardiomyocytes and cardiac fibroblasts, we detected no toxicity at Mo concentrations up to 0.52 mM. To test Mo TEPW in vivo, we sutured them epicardially onto the anterior wall of hearts of female Wistar rats, led them out of the thorax and placed them in a subcutaneous pocket. We tested electrophysiological properties directly after implantation, after two weeks and one month. Mo electrodes showed similar pacing and sensing properties directly upon implantation and after two weeks. After one month, all but one pair of Mo electrodes were mechanically broken at their exit from the thorax, the site of assumedly highest mechanical stress. Conventional steel TEPW had similar electrical properties following implantation, after two weeks and one month with no signs of breakage. Conclusion: We demonstrate that Mo TEPW can feasibly be used for epicardial pacing in vivo for up to two weeks. These findings represent an important step in the development of bioresorbable TEPW as a novel and even safer approach to temporary epicardial pacing.

PO-04-078 WHEN THE Q RUNS AWAY FROM P: A CASE OF EXTREME MOBITZ TYPE I

Advanced infranodal conduction disease usually presents with Mobitz 2 pattern and normal or mildly prolonged conducted PR intervals, whereas advanced AV node disease presents with Mobitz 1 pattern and more pronounced PR prolongation of conducted beats. AV node conduction properties can vary, with some patients demonstrating markedly prolonged PR intervals. We present a case of extreme PR prolongation and highly unusual Mobitz 1 patterns. To emphasize the variable presentation of AV node disease. N/A A 60 year old man with a history of Tetralogy of Fallot had serial repair surgeries over the years, including a Blalock Tausig shunt, Tetralogy of Fallot repair with pulmonary valve replacement, tricuspid valvuloplasty with chordal re-attachment, and closure of a cleft in the septal tricuspid valve leaflet. He had a dual chamber pacemaker for second degree AV block and RBBB. Due to recurrent tricuspid valve dysfunction, his pacemaker and leads were explanted at the time of repeat tricuspid valve surgery. Post-operatively, the surgical temporary epicardial pacing wires were not initially used, and various forms of asymptomatic Mobitz type 1 AV block were seen on serial ECGs. Careful scrutiny of the ECGs showed that the PR interval ranged from 640 ms to over 1300 ms. The markedly prolonged PR intervals led to highly unusual AV relationships, including overlapping PR intervals, as well as 1:1 and 2:1 AV conduction patterns that could only be properly deciphered in the context of other ECGs. When 2:1 AV conduction was seen, temporary pacing was implemented. He subsequently underwent bi-v pacemaker implantation to achieve proper AV and VV synchrony, in the context of concurrent LV dysfunction. AV conduction patterns can become complex in the setting of AV node disease, and more dramatically so in the context of congenital heart disease and valve surgery. Associations between specific P waves and QRS complexes should be ascertained to properly appreciate AV node disease severity. In the presented case, cursory ECG assessment led the ICU clinical team to conclude that AV conduction in the post-op setting followed a simple Mobitz 1 pattern with typical PR intervals. Therefore surgical temporary pacing wires were not utilized until the patient developed 2:1 AV conduction with more marked bradycardia. With careful ECG analysis, the severity of AV node dysfunction could be properly assessed and managed.

Practice Patterns of Antithrombotic Therapy during the Early Postoperative Course of Cardiac Surgery

The current practices regarding the management of antithrombotic therapy during the early postoperative course of cardiac surgery are not well described. An online survey with multiple-choice questions was sent to cardiac anesthesiologists and intensivists from France. The response rate was 27% (n = 149), with 2/3 of the respondents having less than 10 years of experience. A total of 83% of the respondents reported using an institutional protocol for antithrombotic management. A total of 85% (n = 123) of the respondents regularly used low-molecular-weight heparin (LMWH) during the immediate postoperative course. For 23%, 38%, 9%, and 22% of the physicians, LMWH administration was initiated between the 4th and 6th hour, between the 6th and 12th hour, between the 12th and 24th hour, and on postoperative day 1, respectively. The main reasons for not using LMWH (n = 23) were a perceived increased risk of perioperative bleeding (22%), poor reversal compared with unfractionated heparin (74%), local habits and the refusal of surgeons (57%), and its overly complex management (35%). The modalities of LMWH use were widely varied among the physicians. Chest drains were mostly removed within 3 days of surgery with an unchanged dose of antithrombotic therapy. Regarding temporary epicardial pacing wire removal anticoagulation, 54%, 30%, and 17% of the respondents left the dose unchanged, suspended the anticoagulation, or lowered the anticoagulation dose, respectively. LMWH was inconsistently used after cardiac surgery. Further research is warranted to provide high-quality evidence regarding the benefits and safety of LMWH use early after cardiac surgery.

Retention of temporary epicardial pacing wires: when migration causes dehiscence of a sternal wound.

Retention of temporary epicardial pacing wires: when migration causes dehiscence of a sternal wound.

1132 CATHETER INTERVENTION TO TREAT MIGRATED TEMPORARY EPICARDIAL PACING WIRE INTO THE PULMONARY ARTERY

Abstract Catheter intervention to treat migrated temporary epicardial pacing wire into the pulmonary artery Introduction Temporary epicardial pacing wires (TEPW) are routinely inserted postoperatively for treating electrophysiological disturbances after open-heart surgeries. They are typically placed on the surface of the right ventricle and the right atrial appendage. They are usually removed before discharge, but in case of difficult removal, they are cut flush to the skin, and thus retained. Leaving TEPW can be associated to complications, especially with wires migration. As described in literature, TEPW migration is rare and typically involves the right side of the heart, even if any part of the body can be involved. A review proposed an algorithm for removal decision making, based on the risk of serious complications like infection, dissection and perforation. We present a case of a transcatheter removal of a TEPW migrated into the pulmonary artery, in an asymptomatic patient. Case presentation A 52 year-old man, with previous history of Hodgkin Lymphoma treated with radiotherapy and Chemotherapy; CAD (inferior AMI treated with CABG); constrictive pericarditis causing many on-hospital admissions for heart failure; valvular disease: together with the CABG intervention, in 2012, he underwent mitral valvular repair and aortic valvuloplasty; in 2018, because of mitral valve repair failure, he underwent mitral valve substitution with a mechanic valve together with tricuspid repair; in the same year, because of worsening aortic regurgitation, he underwent TAVI. During routine follow-up exams, three years later, in 2021, the patient underwent a total body CT scan that showed the presence of a hyperintensity signal in the region between the right atrium and the right ventricle, crossing the tricuspid valve, with a final loop in the right ventricle infundibulum, suspected to be a TEPW. A transthoracic echocardiogram confirmed the position of the extraneous body, that was causing no impingement to the leaflets of the tricuspid valve, without worsening tricuspid regurgitation. A fluoroscopy showed the presence of a metallic wire, divided into two segments, the former extended from the right atrium till the right subclavian vein passing through the superior cava vein; the latter extended from the right ventricle till the left pulmonary artery. The patient underwent a transcatheter intervention with a right femoral vein access, to try to remove the TEPWs. The former located in the right atrium had a extravascular location, so it was left inside. The other one was removed. After advancing a Swan-Ganz catheter into the pulmonary artery, it was exchanged with a multipourpose catheter and a Multi-Snare 20 mm retrieval system captured the wire and dragged till the inferior cava vein; a second retrieval system, a Snare STD 12-20 mm, was finally able to anchor firmly the wire and to carry it outside. No complications occurred after the procedure; an echocardiogram excluded intracardiac problems. The patient was discharge the day after the procedure, in good clinical conditions. Discussion In this case, a transcatheter removal of the TEPW was performed, even if the presence of the wires caused no symptoms and/or complications to the patient. Anyway, because of the presence of both a prosthetic valve and a mechanic valve, in a setting of constrictive pericarditis and the consequent possibility of several in-hospital admission in conditions of acute heart failure with worsening of tricuspid regurgitation, the persistence of the wire could represent a risk factor for infective endocarditis and for severe tricuspid regurgitation. Removing it with a fast and safe transcatheter femoral approach, a potential cause of other complications was avoided.

S2558 An Unusual Cause of Upper Gastrointestinal Bleed: Temporary Epicardial Pacing Wire

Introduction: A temporary epicardial pacing wire (TEPW) is frequently placed during cardiac surgery to treat postoperative arrhythmias. Gastrointestinal (GI) complications from TEPW are rare, and only a few have been described. Here we describe a rare case of upper GI bleed from TEPW traversing the stomach. Case Description/Methods: A 76-year-old male with a past medical history of coronary artery disease (CAD) status posts two stents, myocardial infarction, chronic kidney disease, hypertension, and stroke presented to the emergency department with chest pain. The patient had a non-ST-elevation myocardial infarction (NSTEMI); coronary angiography showed multivessel CAD. He underwent coronary artery bypass grafting (CABG), following which the patient had 1200cc dark blood drained through the nasogastric tube. The patient underwent esophagogastroduodenoscopy (EGD), which showed a significant amount of fresh blood (Figure A) and a suspicious linear object entering and exiting the gastric body (Figure B). He underwent a celiac and left gastric artery angiogram with embolization of the injured branch of the left gastric artery. The foreign body removed from the stomach was identified as right ventricle TEPW. Repeat EGD showed no active bleeding. Discussion: Epi-myocardium of the atria and ventricle are common sites for TEPW placement during cardiac surgery. They are tunneled to the outside through the left subcoastal margin. Poor sensing or capture, dislodgement, or retention are the most common complications. Other complication include bleeding from the right ventricular laceration with tamponade, avulsion of a side branch from a saphenous vein coronary bypass graft, and perforation of the superior epigastric artery. GI complications from this procedure are rare. Few reports of bowel perforation presenting as acute abdomen have been described. A case of dyspepsia due to gastric wall injury caused by the migration of TEPW into the gastric cavity has been described. To our knowledge, no case of upper GI bleed secondary to pacemaker wire misplacement has been described. Post-cardiac surgery patients are usually in the ICU. Therefore, if signs of GI bleeding are present in the postoperative period, EGD should be performed for diagnostic purposes. However, rarely displaced pacemaker wire may be one of the causes of GI bleeding, which should be on the physician's radar.Figure 1.: (A) EGD showing pooled blood in stomach giving definitive evidence of upper GI bleed. (B) EGD showing pacemaker wire traversing the stomach.

Temporary epicardial pacing wires post-cardiac surgery: a literature review.

Although epicardial pacing wires are routinely inserted after cardiac surgical procedures, there is little in the medical literature to help standardise their use and identify associated risks and benefits. Much of the decision-making surrounding pacing wires are based on the surgeon's preference and vary highly between centers. A literature review was conducted exploring the evidence, indications, and current practice for temporary pacing wires. Risk factors for developing post-operative arrhythmias necessitating use of temporary pacing wires and complications were also reviewed. Although temporary epicardial pacing wires have a crucial role to play in the post-operative recovery period, the current literature suggests that they should be considered on an individual basis in all high-risk patients including increased age, low ejection fraction, diabetes mellitus, elevated pulmonary artery pressures, prolonged cross clamp time, pacing required to wean from bypass, pre-operative arrhythmia, and multiple valvular and transplant operations. Although complications from pacing wires are low, this figure is likely underreported and further studies are required to focus on the risks and benefits of insertion.

Temporary epicardial pacing wires in isolated Coronary Artery Bypass Graft: Necessity or force of habit?

To determine the frequency of Temporary epicardial pacing wires usage and its predictors in the immediate postoperative period in isolated coronary artery bypass graft surgery. The longitudinal study was conducted at the Aga Khan University Hospital, Karachi, from September 2019 to August 2020, and comprised adult patients of either gender who underwent isolated coronary artery bypass graft in the Department of Cardiothoracic Surgery. Demographic, peri-operative and post-operative Temporary Epicardial Pacing Wires use data was extracted from patient's files and the institutional electronic database. Logistic regression models were built to explore predictors of Temporary epicardial pacing wires usage. Data was analysed using SPSS 22. Of the 322 cases evaluated, 27(8.4%) required the use of Temporary Epicardial Pacing Wires. Mean age of the patients requiring temporary epicardial pacing wires was 66.3±8.9 years compared to 58.7±8.9 years in those who did not require it (p<0.001), while the left ventricular ejection fraction percentage was 44.1±12.8 and 48.9±12.8 respectively (p=0.032). After adjusting for clinically plausible demographics and peri-operative variables, increasing age and low left ventricular ejection fraction were significantly associated with the use of temporary epicardial pacing wires in post-operative period of isolated coronary artery bypass graft patients (p<0.05). The frequency of temporary epicardial pacing wires usage in the post-operative period of coronary artery bypass graft was found to be low.

B-PO05-061 SAFETY OF INTRAOPERATIVE PLACEMENT OF PERMANENT LEADLESS PACEMAKERS COMPARED TO TEMPORARY EPICARDIAL WIRE PLACEMENT

Since the risk of post-op bradyarrhythmias is high after tricuspid valve or aortic valve surgery, placement of temporary epicardial pacing (TEP) wires has a Class I indication. Intraoperative placement of a leadless cardiac pacemaker (LCP) avoids the need for monitoring with TEP and their associated complications. To compare the safety of intraoperative LCP against post-operative monitoring with TEP wires in patients who ultimately undergo pacemaker placement. Single-center review of patients who underwent valve surgery from 8/2018-11/2020 and received an LCP (Medtronic, Micra) either i) intraoperatively without adjunctive TEP wires (n=23; Figure) or ii) post-operatively with TEP (n = 23). There were no procedural complications/adverse pacing events with intra-operative LCP implantation without TEP wire placement. Of patients with TEP in place, two (8.7%) required urgent implantation of transvenous pacing leads after pacing needs developed post-TEP removal. One patient received an urgent permanent pacemaker after TEP leads failed and lost capture. TEP wires remained in place for a median of 9 days. Despite additional monitoring in the TEP group, both groups had similar rates of moderate pacing (>40% RV pacing) at 30-day follow-up (44% TEP vs 28% Intraop, p = 0.298). There were no pacing related complications in patients who underwent intraoperative LCP implantation without temporary epicardial leads. Temporary epicardial leads have been associated with pacing related complications (R-on-T) and can fail over time. Studies on the financial implications of this strategy are warranted.

A Soft and Absorbable Temporary Epicardial Pacing Wire.

Existing temporary epicardial pacing wires (TPWs) are rigid and non-absorbable, such that they can cause severe complications after cardiac surgery. Here, a soft and absorbable temporary epicardial pacing wire (saTPW) for effectively correcting abnormal heart rates in a rabbit model, such as bradycardia and ventricular premature beat, is developed. The saTPW exhibits excellent conductivity, flexibility, cycling stability (>100000 cycles), and less inflammatory response during two-month subcutaneous implantation in a rat model. The saTPW which consists of poly(l-lactide-co-ε-caprolactone) and liquid metal, can degrade about 13% (mass loss) in the rats over a two-month subcutaneous implantation. It can be absorbed over time in the body. The cytocompatibility and absorbability avoid secondary injuries caused by remaining wires which are permanently left in the body. The saTPW will provide a great platform for diagnosis and treatments in cardiovascular diseases by delivering the physiological signal and applying electrical stimulation for therapy.

Management of temporary epicardial pacing wires in the cardiac surgical patient.

Temporary epicardial pacing wires are used after cardiothoracic surgery to maintain a stable cardiac rhythm. They must be distinguished from the more commonly encountered transvenous temporary pacing wires, which are often used in coronary care units for the same purpose. Patients with temporary epicardial pacing wires may be transferred to hospital wards where these wires are not usually encountered, such as COVID wards, the general intensive care unit, the coronary care unit or general surgical wards if a laparotomy was required in the early period following cardiac surgery. Serious complications may arise in managing patients with temporary epicardial pacing wires, which are well known in the cardiothoracic unit but not so well known elsewhere in the hospital. This article discusses the dangers associated with the management of temporary epicardial pacing wires in adult patients, some of which are common to temporary transvenous pacing wires and others are unique to temporary epicardial pacing wires.

Early discharge after temporary epicardial pacing wire removal: a retrospective cohort study

Background/Aims Insertion of temporary epicardial pacing wires is a common procedure following cardiac surgery. Complications related to their removal, though rare, can be fatal. There are no nationally recognised guidelines on the removal of pacing wires or safe discharge thereafter. This study aimed to evaluate the safety of discharging stable cardiac surgery patients, who meet all other discharge criteria, within 4–24 hours of epicardial pacing wire removal. Methods A single-centre retrospective cohort study was conducted with all consecutive cardiac surgery patients who underwent temporary pacing wire insertion at a tertiary centre for cardiac surgery (n=250). Patient records were retrospectively reviewed to extract and collate variables related to the procedure, as well as acute and long-term adverse outcomes. Data were analysed using a variety of statistical tests, with P&lt;0.005 being taken to indicate significance. Results No significant difference was observed in the incidence of acute (P=0.646) or long-term complications (P=0.118) between patients discharged before 24 hours after wire removal and those discharged later. Patients with moderate or severe resistance to removal were significantly more likely to experience acute complications (P&lt;0.001). Patients with an international normalised ratio of &gt;2 at removal showed significantly more long-term complications (40.9% vs 16.2%, P=0.02). Conclusions The practice of discharging patients within 24 hours after pacing wire removal, if all other discharge criteria are met, is safe. High resistance and an elevated international normalised ratio (&gt;2) at the time of removal are independent predictors of acute and long-term complications. Such patients should be closely monitored after removal and might benefit from delayed discharge. Further research should be conducted to make this study's results more generalisable and to formulate guidelines to standardise practice.

Safety and image quality of cardiovascular magnetic resonance imaging in patients with retained epicardial pacing wires after heart transplantation

BackgroundTemporary epicardial pacing wires, implemented in patients during heart transplantation, are routinely removed before discharge. However, in some cases, these wires may remain in situ and are often considered as a contraindication for cardiovascular magnetic resonance (CMR) imaging in the future. Therefore, we aimed to provide data about safety and image quality of CMR in these patients.Methods This is a report on a subpopulation out of 88 patients after heart transplantation that were included in a prospective cohort study and underwent multiple CMR in their post-transplant course. During CMR, patients were monitored by electrocardiogram and all examinations were observed by a physician to document potential adverse events. Additionally, image quality was assessed by an imaging specialist.ResultsNineteen of 88 patients included had temporary pacing wires in situ. These patients underwent a total of 51 CMR studies. No major adverse event and only one single, mild sensory event could be documented. All CMR studies showed preserved diagnostic image quality. Temporary pacing wires were visible in 100% of HASTE and cine sequences. In less than 50% of the examinations, temporary pacing wires were also visible in T1 and T2 mapping, short tau inversion recovery (STIR), and late gadolinium enhancement (LGE) sequences, without any impairment of image quality.ConclusionsWith a low event rate of only one mild adverse event during 51 CMR examinations (2%), CMR appears to be safe in patients with retained temporary epicardial pacing wires after heart transplantation. Moreover, image quality was not impaired by the presence of pacing wires.

Improper Use of Temporary Epicardial Pacing Wires.

Improper Use of Temporary Epicardial Pacing Wires.

Bronchial Penetration of Migrated Temporary Epicardial Pacing Wire with Bronchoscopic Extraction

Bronchial Penetration of Migrated Temporary Epicardial Pacing Wire with Bronchoscopic Extraction

Spontaneous transmyocardial migration of an abandoned temporary epicardial pacing wire

A 62-year-old man who had undergone coronary artery bypass grafting (CABG) surgery five years previously in the other hospital presented for cardiac computed tomography angiography (CTA). Three yea...

Prediction of temporary epicardial pacing wire use in cardiac surgery.

Placement of temporary epicardial pacing wires (TEPW) at the end of open heart surgery cases is routine but can be associated with complications. Identification of patients who are high risk for requiring pacing would be beneficial on guiding selective TEPW placement. The purpose of this study was to identify predictors of temporary pacing immediately post cardiac surgery. A retrospective analysis of patients undergoing cardiac surgery from 2005 to 2016 at the Maritime Heart Center was conducted. Analysis was performed of patients who require pacing on arrival to the cardiovascular intensive care unit (CVICU) compared with those who were not paced. Multivariable logistic regression was used to determine each variable's risk adjusted likelihood of pacing for the entire cohort. Subgroup analysis was performed in the isolated procedures. A total of 11 752 patient underwent surgery from the year 2005 to 2016. Two thousand and fifty-one (17.5%) required pacing on arrival to CVICU. Older age, female sex, preoperative renal failure, lower ejection fraction (EF), preoperative arrhythmia, preoperative use of calcium channel blockers, and longer cross-clamp times were risk factors for pacing. In the isolated coronary artery bypass grafting and aortic valve replacement groups, findings were similar to the overall cohort. Only age, obesity, and chronic obstructive pulmonary disease were risk factors for pacing in the isolatedmitral valve (MV) repair group and only preoperative arrhythmia in the isolated MV replacement group. We have identified risk factors for TEPW use following cardiac surgery and in isolated procedure subgroups. These risk factors may help guide selective TEPW placement.

Epicardial pacing wires after cardiac surgery: an Irish cross-sectional study.

Temporary epicardial pacing wires are inserted after cardiac surgery. However, there are no international guidelines on which to base best practice regarding wire insertion or removal. Data were collected on patients following cardiopulmonary bypass and analysed in terms of use, duration of use and complications of pacing wires after surgery. Wires were inserted in 164 of the 167 patients. Most (74%) did not require pacing. Patients were categorised into those who had aortic valve replacement (AVR) (n=42) and those who did not (n=122). Of the AVR group, 26% (n=11) were pacemaker dependent after surgery and 10% (n=4) required permanent pacemakers. Most pacing wires were removed by day 4. The only noted complication was delayed discharge. Unused pacing wires are normally removed on day 4, but for 77 (47%) of patients they remained in place longer. Forty patients (24%) had delayed wire removal because of a policy of wire removal during business hours only. Of these 40 patients, 27 (17% of the 77 with delayed removal) had delayed discharge as a result of our wire removal policy.

Incidence of tamponade following temporary epicardial pacing wire removal.

Placement of temporary epicardial pacing wires (TEPW) is common practice in cardiac surgery. Removal of TEPW in the postoperative period can lead to serious bleeding necessitating surgical intervention and conferring high morbidity. The purpose of this study is to determine the incidence of TEPW removal complications. A retrospective review of all major cardiac operations at our institution from 2005 to 2016 was conducted. Patients were identified using the Maritime Heart Center Database. We reviewed preoperative, intra-operative, and postoperative characteristics of patients who returned to the operating room more than or equal to 3 days after their index operation to identify those who had bleeding and/or tamponade as a consequence of TEPW removal and any subsequent morbidity. A total of 11 754 patients underwent cardiac surgery at our institution between 2005 and 2016. Of these patients, 88 (0.75%) went back to the operating theater for bleeding and/or tamponade more than or equal to 3 days from their initial index operation. Of these, 11 (0.09%) were secondary to TEPW removal where two (0.017%) suffered irreversible anoxic brain injury. All 11 patients were on antiplatelet therapy with the addition of either deep venous thrombosis (DVT) prophylaxis or therapeutic anticoagulation, which is the standard of care at our institution. Bleeding complications following TEPW removal are rare but have significant consequences including increased hospital length of stay, resource utilization, and morbidity. Standardized practice to address antiplatelet, DVT prophylaxis, and anticoagulation before removal may help further reduce the incidence of serious bleeding events.