Transcript Epicardial Pacing

Alpay Celiker M.D.
Acıbadem University
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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
 Leads
◦ Endocardial, or
epicardial
◦ Passive or active fixation
 Chamber
Paced
◦ VVIR, DDD, or VDD
Pros and Cons of
Transvenous Leads
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• Venous obstructions
Leads generally more
reliable than epicardial • Pace related impaired
ventricular function.
implants
• Lead infections
Procedure more easy
• Lead extraction
Less thresholds
necessity
Fast adaptation to new
• Interaction with cardiac
pacemaker systems
valves
• Impossible in some
patients
Venous Occlusion: 11 out of 85
(13%) total venous obstruction;
10 (12%) partial obstruction. Age,
body size and lead type not
associated with occlusion > 3
years . Bar Cohen 2006
Tricuspid valve issue: 27
out of 123 TR increased.
No severeTR. No change
(63%) or improved
(12%). Berul 2008.
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
Perioperative Infections
(before discharge):
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Staphylococcus
◦Superficial 1,2 %
◦Deep 0,2 %
Early Pacemaker Infections
(< 60 days)
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◦Superficial 3,1 %
◦Deep 1,2 %
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species
were isolated in 44 %
Increased Risks
◦Reintervention
◦Down syndrome
◦Subcutaneous 
preperitoneal pocket
Late Pacemaker Infections
◦Superficial 0,5 %
◦Deep 0,7 %
* Cohen et al J Thorac Cardiovasc
Surg 2002; 124.
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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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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
Pros:
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Venous access not
required
Usable patients with
compromised venous
access
Allows left ventricular
pacing, even in small
patients
Dual chamber pacing in
small patients
Implantation procedure more
invasive than endocardial
• Surgery required
• Leads are weaker
•
Epicardial:
<15 kg
Compromised venous access or a univentricular
heart
Pace the left ventricle
Endocardial
Possible implant <15kg
Venous occlusion
Risks of future lead extraction
Beware of pacing induced heart failure
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
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.
RV PACE (N=10
LV PACE (N=15)
Interventricular mechanical delay (ms)
62±15
17±10
Septal-to-posterior wall motion delay
(ms)
294±84
59±23
Septal-to-lateral wall delay, by TDI (ms)
59+12
40±19
LV mechanical delay, 2D strain (ms)
Mitral valve level
159±44
72±31
LV mechanical delay, 2D strain (ms)
Papillary muscle level
127+25
64±23
RV mechanical delay, 2D strain (ms)
62±33
57±23
RV (ms)
197±42
210±43
LV ejection fraction (%)
45±6
60±6
LV end-systolic volume index (mL)
33±11
22±5
Aortic velocity – time integral (cm)
21±2
26±4
LV Tei index
0,63±0,11
0,38±0,07
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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.
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
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Cons: Two leads required,
larger generator, faster
heart rates than VVIR,
pacemaker mediated
tachycardia
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Advantages
◦ Single lead dual
chamber sensing
◦ Avoid of many
electrodes
◦ Provide AV Synchrony
◦ Avoid of venous
thrombosis??
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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
• 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?
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)
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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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.