Twenty-Seven Years Experience With Transvenous Pacemaker Implantation in Children Weighing <10 kg

Abstract

Original ArticleBackground-Epicardial pacemaker implantation is the favored approach in children weighing <10 kg in many units. The high incidence of premature failure and fractures with earlier epicardial leads led our unit to undertake transvenous pacemaker implantation in neonates and infants from 1987. To date there have been no long-term follow-up reports of what is for many a controversial strategy. Methods and Results-Between 1987 and 2003, 37 neonates and infants-median age 6.7 months (1 day to 3 years) and median weight 4.6 kg (2.7-10 kg)-had a permanent transvenous pacing system implanted. Pacing leads were placed into the right ventricular apex/outflow tract through a subclavian vein puncture with a redundant loop in the atrium. Three patients were lost to follow-up, 4 patients died from complications of cardiac surgery, and 2 patients had their system removed. At long-term follow-up in 28 patients at a median of 17.2 (range, 11.2-27.4) years, 10 patients have a single chamber ventricular pacemaker, 14 a dual chamber pacemaker, 3 a biventricular pacemaker, and 1 has a single chamber implantable cardioverter defibrillator. Subclavian vein patency was assessed in 26 patients. The overall subclavian vein occlusion rate was 10 of 13 (77%) <5 kg and 2 of 13 (15%) >5 kg during long-term follow-up. After a median of 14.3 (range, 13.4-17.6) years of pacing, 7 patients continue with their original lead. Conclusions-Transvenous pacing in infants <10 kg results in encouraging short-and long-term clinical outcomes.Subclavian vein occlusion remains an important complication, occurring predominantly in those weighing <5 kg.(Circ Arrhythm Electrophysiol. 2016;9:e003422.

Marcapasos endocárdico en un prematuro con bloqueo AV y <i>situs inversus</i> total

“…www.medigraphic.org.mx ser inversamente proporcional al peso), pero no se ha descrito colapso completo del acceso venoso. 14 A largo plazo se ha visto que la complicación más frecuente es el estiramiento del electrodo. Nakamoto y colegas 15 describieron a un paciente en quien se decidió exceder la porción endovascular del cable (8 mm), con el fin de evitar dicha eventualidad.…”

“…Por otro lado, la estimulación endocárdica tiende a te-ner un mejor umbral (aurícula y ventrículo) y un mejor acceso a los sitios de estimulación en comparación a la técnica abierta. 14,15 En niños con peso menor a 10 kg, los sistemas de estimulación pueden ser endo-o epicárdicos. Silvetti y colaboradores 16 reportaron 287 pacientes con marcapasos, de los cuales 40.7% tenía sistema endocárdico; el análisis mostró un riesgo mayor de falla en los pacientes con implantes epicárdicos comparado con quienes se implantó de forma endocárdica (50% versus 13%), lo cual fue estadísticamente significativo (p < 0.0001).…”

Pacemakers and Other Cardiac Implantable Devices in Children

“…Clinical reports describing outcomes of CIED including pacemakers for children and adult patients with congenital heart disease often provide conflicting results. Prospective randomized trials or registries of CIED use in children and congenital heart disease are rare, and nearly all published data come from retrospective studies like the current report from Konta et al 2 As a result, guidelines that address appropriate indications for pacemaker and implantable cardioverter defibrillator use in children and congenital heart disease are supported by suboptimal levels of evidence (only B and C in the most recent American College of Cardiology (ACC)/American Heart Association/The Heart Rhythm Society 2008 Guidelines). 3 Another consequence of suboptimal evidence in the area of pacemaker use for children and congenital heart disease is a lack of published guidelines beyond basic pacing indications.…”

“…It is also possible that fine details of the implant technique performed by this solo implanter, including methods for venous access, lead tie down, vascular maneuvers, lead slack placement, 2 Saarel and Aziz CIED in Children: Learning From Practice Variation have lead to the superior performance for endocardial leads in the very young patients in this series. Konta et al 2 do not affirm or refute cases of thrombosis or thromboembolism beyond the subclavian vein, including no report of stroke or systemic thromboembolism, despite the known risk for events with endocardial leads in the reported patient population that includes congenital heart disease and patent foramen ovale (patent foramen ovale was not addressed in the report by Konta et al, 2 but presumably present in most newborns and at least 25% of older children with normal anatomy) with a potential for endocardial right to left shunt. 11 Overall, Konta et al 2 are to be congratulated; they have taken the road less travelled and their smallest patients have benefitted from their expertise and fortitude with excellent outcomes of long-term endocardial cardiac pacing.…”

Pacing and Defibrillators in Complex Congenital Heart Disease

“…21 However, selected patients <10 kg may continue to be treated with an endovascular system. 22 For those in whom an endovascular approach is most appropriate, a comprehensive evaluation of shunts (or potential shunts) by echocardiography or angiography should be undertaken before lead implantation (Class 1C recommendation), 3 in order to evaluate for thromboembolic risk. Thin lumenless pacing leads (model 3830 SelectSecure ® , Medtronic Inc.) may reduce complications in smaller patients and those with limited venous lumens.…”