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Perumal G, Marathe SP, Betts KS, Suna J, Morwood J, Wildschut J, Mattke AC, Alphonso N, Venugopal P. Universal implantation of temporary epicardial pacing wires after surgery for congenital heart disease: necessity or luxury? Eur J Cardiothorac Surg 2021; 57:581-587. [PMID: 31647532 DOI: 10.1093/ejcts/ezz285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 09/08/2019] [Accepted: 09/17/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Routine implantation of temporary epicardial pacing wires after surgery for congenital heart disease (CHD) has recently been questioned. We evaluated the incidence of arrhythmias, arrhythmias causing haemodynamic compromise and the safety of a strategy of selective implantation of pacing wires in our unit. METHODS All patients who underwent surgery for CHD using cardiopulmonary bypass between September 2015 and December 2016 were retrospectively enrolled in the study (n = 313). Patients were stratified into group A (universal implantation) and group B (selective implantation). Group B received pacing wires only when postoperative rhythm disturbances were anticipated based on the operating surgeon's judgement. The primary outcome was arrhythmia causing haemodynamic compromise. Outcomes were compared between unmatched and propensity matched groups. RESULTS Forty-eight patients experienced an arrhythmia causing haemodynamic compromise (15.3%). Twenty-three patients (7.3%) experienced an arrhythmia causing haemodynamic compromise that required the use of pacing wires for therapeutic purposes (group A n = 13, group B n = 10, P = 0.34). There were no pacing wire related complications in either group. All patients in group A and 90% in group B had pacing wires when needed (P = 0.435). In group A, 89% of patients had pacing wires which were not used compared with 13% in group B (P < 0.001). Results were unchanged when repeated using propensity matching (81 pairs). CONCLUSIONS The probability of developing a postoperative arrhythmia requiring therapeutic pacing can be predicted using the risk factors identified in our study. The routine implantation of pacing wires after surgery for CHD is not necessary. A measured reduction from universal implantation is safe.
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Affiliation(s)
- Gopinath Perumal
- Queensland Paediatric Cardiac Service/Queensland Paediatric Cardiac Research, Queensland Children's Hospital, Brisbane, QLD, Australia.,Children's Health Queensland Clinical Unit, School of Clinical Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Supreet Prakash Marathe
- Queensland Paediatric Cardiac Service/Queensland Paediatric Cardiac Research, Queensland Children's Hospital, Brisbane, QLD, Australia.,Children's Health Queensland Clinical Unit, School of Clinical Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Kim S Betts
- Department of Epidemiology, Institute for Social Science Research, University of Queensland, Brisbane, QLD, Australia
| | - Jessica Suna
- Queensland Paediatric Cardiac Service/Queensland Paediatric Cardiac Research, Queensland Children's Hospital, Brisbane, QLD, Australia.,Queensland University of Technology, School of Nursing, Brisbane, QLD, Australia
| | - Jim Morwood
- Queensland Paediatric Cardiac Service/Queensland Paediatric Cardiac Research, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Jason Wildschut
- Queensland Paediatric Cardiac Service/Queensland Paediatric Cardiac Research, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Adrian C Mattke
- Pediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia.,Paediatric Critical Care Research Group, Children's Health Research, Children's Health Queensland, Brisbane, QLD, Australia
| | - Nelson Alphonso
- Queensland Paediatric Cardiac Service/Queensland Paediatric Cardiac Research, Queensland Children's Hospital, Brisbane, QLD, Australia.,Children's Health Queensland Clinical Unit, School of Clinical Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Prem Venugopal
- Queensland Paediatric Cardiac Service/Queensland Paediatric Cardiac Research, Queensland Children's Hospital, Brisbane, QLD, Australia.,Children's Health Queensland Clinical Unit, School of Clinical Medicine, University of Queensland, Brisbane, QLD, Australia
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Selective Use of Temporary Epicardial Pacing Leads in Early Infancy Following Cardiac Surgery: Feasibility and Determinants of Clinical Application. Pediatr Cardiol 2019; 40:630-637. [PMID: 30564866 DOI: 10.1007/s00246-018-2037-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 12/05/2018] [Indexed: 10/27/2022]
Abstract
Use of temporary epicardial pacing (TEP) leads remains a routine perioperative strategy in congenital heart surgery. Selective use of TEP in neonates and infants undergoing cardiac intervention within the first 6 months of life has, yet, to be assessed. Outcome analysis was undertaken. From August 2014 to December 2016, 112 consecutive neonates and infants underwent cardiac intervention within the first 6 months of life. Patients with STS/EACTS Congenital Heart Surgery Mortality (STAT categories) 1-5 were prospectively followed from the index cardiac operation until hospital discharge and included in the study. Patients on permanent pacemaker (PPM) prior to the definitive cardiac intervention were excluded. Selective TEP placement was pursued if specific intraoperative indications were met. Determinants associated with the postoperative use of TEP were assessed. TEP leads were placed in 11 (9.8%) (GroupA). Nine was used for diagnostic and/or therapeutic purposes; two had no use (18%). From 101 patients without TEP (GroupB), one required treatment for postoperative dysrhythmia amenable to pacing. Vasoactive-inotrope score, ICU length of stay and time-to-negative balance was not statistically different between groups (p > 0.05). None of 112 patients required PPM insertion during hospital stay. Intraoperative need for cardioversion, attenuated ventricular function, and sustained sinus/AV node dysfunction or non-resolved elevated serum lactate at the time of operating room discharge were found to be predictors for TEP postoperative use. Selective placement of TEP leads is justified during early infancy for congenital heart surgery. Nearly 20% of those with TEP leads in place, even after its selective use, will not be required following surgery. Specific intraoperative parameters can guide the necessity and potential TEP postoperative use.
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Intra-operative arrhythmia predicts post-operative arrhythmia and the need for temporary pacing wires. Cardiol Young 2015; 25:454-8. [PMID: 24495310 DOI: 10.1017/s1047951114000043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Protocols for the placement of temporary pacing wires vary among institutions. Our current protocol is to selectively place temporary pacing wires in those patients who develop haemodynamically significant intra-operative arrhythmia. We wished to identify how effective our current protocol is at identifying who will develop post-operative arrhythmia and need temporary pacing wires. METHODS The charts of 880 patients over 8 years who underwent cardiopulmonary bypass were reviewed to find patients who developed intra-operative arrhythmia, had temporary pacing wires placed, and whether or not they developed post-operative arrhythmia and required utilisation of the pacing wires. RESULTS A total of 87 (9.9%) out of 880 patients who required cardiopulmonary bypass over 8 years had intra-operative arrhythmia and had temporary pacing wires placed. Of these, 59 (67.8%) had post-operative arrhythmia and utilised the pacing wires, whereas 28 (32.2%) did not have post-operative arrhythmia or utilise the pacing wires. In all, seven patients who did not have intra-operative arrhythmia or temporary pacing wires placed developed post-operative arrhythmia. CONCLUSION Intra-operative arrhythmia is predictive of post-operative arrhythmia (70.2%) and our protocol is a sensitive means of identifying those who will develop post-operative arrhythmia (89.3%).
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Gupta P, Jines P, Gossett JM, Maurille M, Hanley FL, Reddy VM, Miyake CY, Roth SJ. Predictors for use of temporary epicardial pacing wires after pediatric cardiac surgery. J Thorac Cardiovasc Surg 2012; 144:557-62. [PMID: 22329984 DOI: 10.1016/j.jtcvs.2011.12.060] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 11/16/2011] [Accepted: 12/14/2011] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The objectives of this study were (1) to determine the use of temporary epicardial pacing wires to diagnose and treat early postoperative arrhythmias in pediatric cardiac surgical patients and (2) to determine the predictive factors for the need of pacing wires for diagnostic or therapeutic purposes. METHODS We collected preoperative, intraoperative, and postoperative data in a prospective, observational format from patients undergoing pediatric cardiac surgery between August 2010 and January 2011 at a single academic children's hospital. RESULTS A total of 157 patients met the inclusion criteria during the study period. Of these 157 patients, pacing wires were placed in 127 (81%). Pacing wires were used in 25 patients (19.6%) for diagnostic purposes, 26 patients (20.4%) for therapeutic purposes, 15 patients (11.8%) for both diagnostic and therapeutic purposes, and 36 patients (28.3%) for diagnostic or therapeutic purposes. Need for cardioversion in the operating room, presence of 2 or more intracardiac catheters, severely reduced ventricular ejection fraction, and elevated serum lactate level at the time of operating room discharge were found to be independent predictors for the use of pacing wires. The only complication noted in the cohort was a skin infection at a pacing wire insertion site in 1 patient. A permanent pacemaker was required in 8 (6.2%) of all patients with temporary pacing wires. CONCLUSIONS Our data support the use of temporary epicardial pacing wires in approximately 30% of children after congenital heart surgery. We found the need for cardioversion in the operating room, presence of 2 or more intracardiac catheters, severely reduced ventricular ejection fraction, and high serum lactate level at the time of discharge from the operating room to be independent predictors of the use of pacing wires in the early postoperative period.
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Affiliation(s)
- Punkaj Gupta
- Division of Pediatric Cardiology, Department of Pediatrics, 1 Children’s Way, Slot 512-3, Little Rock, AR 72202-3591, USA.
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Abstract
OBJECTIVE Temporary pacing wires have been associated with serious postoperative complications. Recommendations for their routine use after open heart surgery are decades old, and may not reflect current surgical techniques and outcomes. METHODS The electronic web-enabled medical records of all patients undergoing congenital cardiac surgery from February, 2002, through December, 2005, were reviewed, excluding patients undergoing implantation of pacemakers as a primary procedure, or those undergoing ligation of a patent arterial duct. RESULTS There were 1193 surgical procedures performed, 1041 with cardiopulmonary bypass. Median age of the patients was 5.8 months, with a range from 0 days to 54 years, weighing 6.2 kilograms, with a range from 1 to 114 kilograms. Mortality prior to discharge was 2.5%, and median postoperative stay was 6 days. No deaths were attributed to arrhythmias. Temporary pacing wires were placed 14 times (1.2%). Indications for placement included sinus nodal dysfunction in 8 patients, preoperative in 4 and intraoperative in 4, high degree atrioventricular block in 4 patients, and intraoperative atrial flutter in 2 patients. Of these patients, 4 (0.3%) eventually underwent permanent implantation of a pacemaker, 2 for persistent sinus nodal dysfunction, and 2 for persistent atrioventricular block. Postoperative junctional ectopic tachycardia requiring antiarrhythmic therapy occurred in 9 patients (0.8%). All recovered without incident, and none were treated with temporary pacing. CONCLUSIONS The diminished risk of unexpected postoperative arrhythmias in the current era alleviates the necessity for routine placement of temporary pacing wires. Those institutions with experienced surgical and cardiac critical care teams may be able to predict the need for temporary pacing wires preoperatively or intraoperatively.
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Deprez F, Blommaert D, De Roy L. An unusual way to diagnose asymptomatic right ventricular perforation by a temporary endocardial pacing electrode. Eur J Emerg Med 2003; 10:250-1. [PMID: 12972908 DOI: 10.1097/00063110-200309000-00021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Right ventricular perforation by a temporary endocardial pacing electrode can be fatal and needs to be detected promptly. This usually symptomatic situation is diagnosed by X-ray or echocardiographic findings. We present the case of a patient with an asymptomatic right ventricular perforation, in whom serial electrocardiograms enabled us to detect the displacement of the right ventricular lead.
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Affiliation(s)
- Frédéric Deprez
- Department of Cardiology, Cliniques Universitaires de Mont-Godinne, Yvoir, Belgium
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