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Pediatric Pacemaker Implantation Periprocedural Care

  • Author: Charles I Berul, MD; Chief Editor: Stuart Berger, MD  more...
 
Updated: Apr 01, 2014
 

Preprocedural Evaluation

For patients with congenital or idiopathic atrioventricular (AV) block, test for maternal lupus antibodies (anti-Ro, anti-La), and measure Lyme titers. AV block due to Lyme carditis is typically reversible with appropriate antibiotic treatment.

Echocardiography is used to determine the underlying anatomy, particularly the presence of L-looping of the ventricles (ie, physiologically corrected transposition of the great arteries), which has a high association with the development of AV block. Echocardiographic data are also useful to assess ventricular function and to determine presence of congenital heart disease or intracardiac shunts.

Phlebography may be helpful before transvenous pacemaker implantation, particularly for patients who have undergone prior surgery or central venous line placement. Arm phlebography can outline the course of the venous system and confirm continuity with the heart. Variants (eg, left superior vena cava to coronary sinus connections and other vascular anomalies) can be easily identified.

Performing chest radiography before pacemaker implantation to identify heart chamber sizes and potential vascular abnormalities (eg, right aortic arch) is reasonable. In addition, imaging should be performed in patients with existing pacing systems to visualize the lead positions.

Electrocardiography (ECG) is essential for documenting the rhythm before the pacemaker is implanted (see the images below).

Electrocardiogram reveals sinus atrial mechanism w Electrocardiogram reveals sinus atrial mechanism with complete atrioventricular block and ventricular paced rhythm.
Electrocardiogram illustrates 2-year-old child wit Electrocardiogram illustrates 2-year-old child with third-degree atrioventricular block.
Electrocardiogram illustrates atrial-synchronous, Electrocardiogram illustrates atrial-synchronous, ventricular paced rhythm.
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Equipment

A pacemaker is an electronic device, approximately the size of a pocket watch, that senses intrinsic heart rhythms and provides electrical stimulation when indicated. Cardiac pacing can be either temporary or permanent.

Permanent pacing is most commonly accomplished through transvenous placement of leads to the endocardium (ie, right atrium or ventricle) or epicardium (ie, to the left ventricular surface via the coronary sinus), which are subsequently connected to a pacing generator placed subcutaneously in the infraclavicular region.

Implantable pacemakers

Permanent pacemakers are implantable devices that sense intrinsic cardiac electric potentials and, if these are too infrequent or absent, transmit electrical impulses to the heart to stimulate myocardial contraction. A specialized type of pacemaker therapy, cardiac resynchronization therapy (CRT) with biventricular pacing, with or without an implantable cardioverter-defibrillator (ICD), has been used as adjunctive therapy for patients with heart failure.

Implantable defibrillators

The implantable cardioverter-defibrillator (ICD) is first-line treatment and prophylaxis for patients at risk for ventricular tachycardia (VT) or ventricular fibrillation (VF). Current devices offer tiered therapy with programmable antitachycardia pacing schemes, as well as low-energy and high-energy shocks in multiple tachycardia zones.

Dual-chamber, rate-responsive bradycardia pacing is now available in all ICDs, and sophisticated discrimination algorithms minimize shocks for atrial fibrillation, sinus tachycardia, and other non–life-threatening supraventricular tachyarrhythmias. Diagnostic functions, including stored electrograms, allow for verification of shock appropriateness.

Pacemaker size and type

Size is an important factor in pacemaker selection, particularly for infants and smaller children. Modern generators have markedly reduced mass, width, and circumference, and single-chamber and dual-chamber devices are now similarly sized.

No pacemaker is specifically designed for pediatric use. Each generator has special features and options, which vary among different manufacturers and specific models. Some features may be particularly appropriate or inappropriate for children. For example, because pacemakers are designed primarily for adults, the resting heart rate is expected to be lower than 100 beats/min. Most pacemakers released before 1996 had a maximum rate limit of 120-130 beats/min, which may be inadequate for a neonate or critically ill postoperative infant.

A programmable lower and upper rate limit may require a higher setting in children to compensate for increased demands on myocardial oxygen consumption, cardiac output response to exercise, and increased predicted maximum heart rates with exertion. Unfortunately, battery longevity is sacrificed in favor of optimizing hemodynamic performance. Because cardiac output is more critically dependent on heart rate in children, the requirement for faster pacing rates increases battery expenditure.

Pacemaker leads

Fixation mechanisms in transvenous leads are divided into active-fixation tips and passive-fixation leads. In general, active-fixation leads are now more commonly used in children because they can be more easily removed if necessary.

Active-fixation leads have a screw on the end that penetrates the endocardium. These mechanisms either are covered in a dissolvable material (eg, gelatin, sugar cap) to protect the delicate veins during insertion or have an intricate screw extension-retraction mechanism that allows the operator to enter the vein and cardiac chambers without an exposed screw.

Active-fixation leads can be fixated almost anywhere in the endocardium; they may be especially valuable for patients with left ventricular lead placements (eg, corrected transposition of great arteries) or those without a right atrial appendage (eg, most postoperative patients with congenital heart disease). Active-fixation leads are more easily removed, even after being implanted for many years. This feature is a distinct advantage for young patients, who may need multiple pacemaker system replacements over a lifetime.

Passive-fixation mechanisms use small tines or fins near the distal tip, which become entrapped in the right ventricular trabeculations and lodge within scar over time. These leads do not require a screw-in device but are facilitated by placement in a trabeculated region, which may not be routinely available in patients with congenital heart disease. Passive-fixation leads are more difficult to extract when implanted for long periods and may be less appropriate for pediatric patients because multiple revisions are anticipated.

The tips of the leads may have special coatings to improve pacing characteristics or to decrease surrounding tissue inflammation. The most common is a steroid-eluting tip, which continually disperses a tiny amount of dexamethasone (or another corticosteroid) into the local tip-tissue interface.[18]

These steroid-eluting leads, available in both passive-fixation and active-fixation tips, prevent subacute threshold rise, which is seen several weeks after lead implantation. This benefit can be critically important in children, who typically have a greater inflammatory response to tissue injury and a larger threshold rise.

Titanium nitride and other metallic compounds also have been used to increase the surface area at the tip-tissue interface; this increased surface area should improve pacing and sensing performance.

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Monitoring and Follow-up

Follow-up is routine and simplified. During the initial few months after surgery, evaluate the patient to assess for a possible rise in capture thresholds secondary to inflammation and exit block. Program a safety margin to avoid possible loss of capture because of a subacute threshold rise, which may be seen in the first several weeks, particularly with epimyocardial implants or non–steroid-eluting leads.

Transtelephonic pacing system evaluation is simple, convenient, and relatively inexpensive, allowing follow-up with fewer cardiology office visits. These systems have become more sophisticated and more automated over the past few years, permitting extensive pacemaker system information to be transmitted over the telephone and internet.

For patients who are pacemaker-dependent, dizziness, presyncope, or syncope warrants a full device interrogation of both leads and pulse generator to ensure proper function of the device.

Children with implanted devices are generally more active than adults; the child’s continuing bodily growth and development create additional concerns and further increase demands on pacing systems. Contact sports add stress and strain on pacemaker generators and leads. Children with pacing devices have higher incidences of lead-related complications than adults, presumably secondary to growth and vigorous exertion. Younger patients are more apt to participate in contact sports and to continue to engage in vigorous activities.

Resumption of normal activities, as feasible, and promotion of healthy development without incurring significant additional risks are important goals of pediatric health care. Physicians must identify potential concerns and obstacles that patients and families may encounter and must offer strategies to guide them through their adjustment.

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Contributor Information and Disclosures
Author

Charles I Berul, MD Professor of Pediatrics and Integrative Systems Biology, George Washington University School of Medicine; Chief, Division of Cardiology, Children's National Medical Center

Charles I Berul, MD is a member of the following medical societies: American Academy of Pediatrics, Heart Rhythm Society, Cardiac Electrophysiology Society, Pediatric and Congenital Electrophysiology Society, American College of Cardiology, American Heart Association, Society for Pediatric Research

Disclosure: Received grant/research funds from Medtronic for consulting.

Chief Editor

Stuart Berger, MD Medical Director of The Heart Center, Children's Hospital of Wisconsin; Associate Professor, Department of Pediatrics, Section of Pediatric Cardiology, Medical College of Wisconsin

Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, Society for Cardiovascular Angiography and Interventions

Disclosure: Nothing to disclose.

Acknowledgements

John W Moore, MD, MPH Professor of Clinical Pediatrics, Section of Pediatric Cardiology, Department of Pediatrics, University of California San Diego School of Medicine; Director of Cardiology, Rady Children's Hospital

John W Moore, MD, MPH is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, and Society for Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Jeffrey Allen Towbin, MD, MSc, FAAP, FACC, FAHA Professor, Departments of Pediatrics (Cardiology), Cardiovascular Sciences, and Molecular and Human Genetics, Baylor College of Medicine; Chief of Pediatric Cardiology, Foundation Chair in Pediatric Cardiac Research, Texas Children's Hospital

Jeffrey Allen Towbin, MD, MSc, FAAP, FACC, FAHA is a member of the following medical societies: American Academy of Pediatrics, American Association for the Advancement of Science, American College of Cardiology, American College of Sports Medicine, American Heart Association, American Medical Association, American Society of Human Genetics, Cardiac Electrophysiology Society, New York Academy of Sciences, Society for Pediatric Research,Texas Medical Association, and Texas Pediatric Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References
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Electrocardiogram reveals sinus atrial mechanism with complete atrioventricular block and ventricular paced rhythm.
Electrocardiogram illustrates 2-year-old child with third-degree atrioventricular block.
Electrocardiogram illustrates atrial-synchronous, ventricular paced rhythm.
Illustration of normal conduction system.
Transvenous ventricular pacemaker in 2-year-old child. Note abundant slack in lead to allow for growth.
Epicardial dual-chamber implantable cardioverter defibrillator in neonate with congenital complete atrioventricular block. Two bipolar suture-on leads (1 on atrium and 1 on ventricle) are attached to DDDR pacemaker in abdomen.
 
 
 
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