Pediatric Pacemaker Implantation Periprocedural Care
- Author: Charles I Berul, MD; Chief Editor: Stuart Berger, MD more...
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).
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.
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.
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.
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.
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.
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.
Alexander ME, Cecchin F, Walsh EP, Triedman JK, Bevilacqua LM, Berul CI. Implications of implantable cardioverter defibrillator therapy in congenital heart disease and pediatrics. J Cardiovasc Electrophysiol. 2004 Jan. 15(1):72-6. [Medline].
DeMaso DR, Lauretti A, Spieth L, et al. Psychosocial factors and quality of life in children and adolescents with implantable cardioverter-defibrillators. Am J Cardiol. 2004. 93:582-7. [Medline].
Silka MJ, Bar-Cohen Y. Pacemakers and implantable cardioverter-defibrillators in pediatric patients. Heart Rhythm. 2006 Nov. 3(11):1360-6. [Medline].
Smerup M, Hjertholm T, Johnsen SP, et al. Pacemaker implantation after congenital heart surgery: risk and prognosis in a population-based follow-up study. Eur J Cardiothorac Surg. 2005 Jul. 28(1):61-8. [Medline].
Chintala K, Forbes TJ, Karpawich PP. Effectiveness of transvenous pacemaker leads placed through intravascular stents in patients with congenital heart disease. Am J Cardiol. 2005 Feb 1. 95(3):424-7. [Medline].
Cecchin F, Frangini PA, Brown DW, et al. Cardiac Resynchronization Therapy (and Multisite Pacing) in Pediatrics and Congenital Heart Disease: Five Years Experience in a Single Institution. J Cardiovasc Electrophysiol. 2008 Sep 3. [Medline].
Dubin AM, Janousek J, Rhee E, et al. Resynchronization therapy in pediatric and congenital heart disease patients: an international multicenter study. J Am Coll Cardiol. 2005 Dec 20. 46(12):2277-83. [Medline].
Epstein AE, DiMarco JP, Ellenbogen KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008 May 27. 51(21):e1-62. [Medline].
Gregoratos G, Abrams J, Epstein AE, et al. ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakersand antiarrhythmia devices: summary article: a report of the American College of Cardiology/AmericanHeart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee t. Circulation. 2002 Oct 15. 106(16):2145-61. [Medline].
Gregoratos G, Cheitlin MD, Conill A. ACC/AHA guidelines for implantation of cardiac pacemakers and antiarrhythmia devices: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Pacemaker Implantation). J Am Coll Cardiol. 1998 Apr. 31(5):1175-209. [Medline].
Horenstein MS, Karpawich PP. Pacemaker syndrome in the young: do children need dual chamber as the initial pacing mode?. Pacing Clin Electrophysiol. 2004 May. 27(5):600-5. [Medline].
Mathony U, Schmidt H, Groger C, et al. Optimal maximum tracking rate of dual-chamber pacemakers required by children and young adults for a maximal cardiorespiratory performance. Pacing Clin Electrophysiol. 2005 May. 28(5):378-83. [Medline].
Ovsyshcher IE, Hayes DL, Furman S. Dual-chamber pacing is superior to ventricular pacing: fact or controversy? [comment]. Circulation. 1998 Jun 16. 97(23):2368-70. [Medline].
Silvetti MS, Drago F. Upgrade of single chamber pacemakers with transvenous leads to dual chamber pacemakers in pediatric and young adult patients. Pacing Clin Electrophysiol. 2004 Aug. 27(8):1094-8. [Medline].
Fishberger SB, Wernovsky G, Gentles TL, et al. Long-term outcome in patients with pacemakers following the Fontan operation. Am J Cardiol. 1996 Apr 15. 77(10):887-9. [Medline].
Noiseux N, Khairy P, Fournier A, Vobecky SJ. Thirty years of experience with epicardial pacing in children. Cardiol Young. 2004 Oct. 14(5):512-9. [Medline].
Stojanov P, Vranes M, Velimirovic D, et al. Prevalence of venous obstruction in permanent endovenous pacing in newborns and infants: follow-up study. Pacing Clin Electrophysiol. 2005 May. 28(5):361-5. [Medline].
Fortescue EB, Berul CI, Cecchin F, Walsh EP, Triedman JK, Alexander ME. Comparison of modern steroid-eluting epicardial and thin transvenous pacemaker leads in pediatric and congenital heart disease patients. J Interv Card Electrophysiol. 2005 Oct. 14(1):27-36. [Medline].
Fortescue EB, Berul CI, Cecchin F, Walsh EP, Triedman JK, Alexander ME. Patient, procedural, and hardware factors associated with pacemaker lead failures in pediatrics and congenital heart disease. Heart Rhythm. 2004 Jul. 1(2):150-9. [Medline].
Berul CI, Hill SL, Estes NA 3rd. A teenager with pacemaker twiddler syndrome. J Pediatr. 1997 Sep. 131(3):496-7. [Medline].
Molina JE, Dunnigan AC, Crosson JE. Implantation of transvenous pacemakers in infants and small children. Ann Thorac Surg. 1995 Mar. 59(3):689-94. [Medline].