Predictors of long-term survival prior to permanent pacemaker implantation in octogenarians or older

Predictors of complications and mortality among patients undergoing pacemaker implantation in resource-limited settings: a 10-year retrospective follow-up study

INTRODUCTION

Pacemakers (PMs) are used to treat patients with severe bradycardia symptoms. They do, however, pose several complications. Even with these risks, there are only a few studies assessing PM implantation outcomes in resource-limited settings like Ethiopia and other sub-Saharan countries in general. Therefore, this study aims to assess the mid-term outcome of PM implantation in patients who have undergone PM implantation in the Cardiac Center of Ethiopia by identifying the rate and predictors of complications and death.

METHODOLOGY

This retrospective study was conducted at the Cardiac Center of Ethiopia from October 2023 to January 2024 on patients who had PM implantation from September 2012 to August 2023 to assess the midterm outcome of the patients. Complication rate and all-cause mortality rate were the outcomes of our study. Multivariable logistic regression was used to identify factors associated with complications and death. To analyze survival times, a Kaplan-Meier analysis was performed.

RESULTS

This retrospective follow-up study included 182 patients who underwent PM implantation between September 2012 and August 2023 and were at least 18 years old. The patients' median follow-up duration was 72 months (Interquartile range (IQR): 36-96 months). At the end of the study, 26.4% of patients experienced complications. The three most frequent complications were lead dislodgement, which affected 6.6% of patients, PM-induced tachycardia, which affected 5.5% of patients, and early battery depletion, which affected 5.5% of patients. Older age (Adjusted Odds Ratio (AOR) 1.1, 95% CI 1.04-1.1, p value < 0.001), being female (AOR 4.5, 95%CI 2-9.9, p value < 0.001), having dual chamber PM (AOR 2.95, 95%CI 1.14-7.6, p value = 0.006) were predictors of complications. Thirty-one (17%) patients died during the follow-up period. The survival rates of our patients at 3, 5, and 10 years were 94.4%, 92.1%, and 65.5% respectively with a median survival time of 11 years. Patients with a higher Charlson comorbidity index before PM implantation (AOR 1.2, 95% CI 1.1-1.8, p = 0.04), presence of complications (AOR 3.5, 95% CI 1.2-10.6, p < 0.03), and New York Heart Association (NYHA) class III or IV (AOR 3.3, 95% CI 1.05-10.1, p = 0.04) were associated with mortality.

CONCLUSION

Many complications were experienced by patients who had PMs implanted, and several factors affected their prognosis. Thus, it is essential to identify predictors of both complications and mortality to prioritize and address the manageable factors associated with both mortality and complications.

The effect of body mass index on complications in cardiac implantable electronic device surgery

BACKGROUND

Cardiac implantable electronic device (CIED) procedures are prone to complications. In our study, we investigated the effect of body mass index (BMI) on CIED-related complications.

METHODS

1676 patients who had undergone CIED surgery (de novo implantation, system upgrade, generator change, pocket revision or lead replacement) at two heart centers in Turkey and met the study criteria were included in our study. For analysis of primary and secondary endpoints, patients were classified as non-obese (BMI < 25 kg/m2 ), overweight (25 ≤ BMI < 30 kg/m2 ), and obese (BMI ≥ 30 kg/m2 ). The primary endpoint was accepted as cumulative events, including the composite of clinically significant hematoma (CSH), pericardial effusion or tamponade, pneumothorax, and infection related to the device system. Secondary outcomes included each component of cumulative events.

RESULTS

The rate of cumulative events, defined as primary outcome, was higher in the obese patient group, and we found a significant difference between the groups (3.0%, 4.3%, 8.9%, p = .001). CSH and pneumothorax rates were significantly higher in the obese patient group (0.3%, 0.9%, 1.9%, p = .04; 1.0%, 1.4%, 3.3%, p = .04, respectively). According to our multivariate model analysis; gender (OR:1.882, 95%CI:1.156-3.064, p = .01), hypertension (OR:4.768, 95%CI:2.470-9.204, p < .001), BMI (OR:1.069, 95%CI:1.012-1.129, p = .01) were independent predictors of cumulative events rates.

CONCLUSIONS

Periprocedural complications associated with CIED (especially hematoma and pneumothorax) are more common in the group with high BMI.

Development and Validation of a Novel Risk Score for All-Cause Mortality Risk Stratification Prior to Permanent Pacemaker Implantation in Octogenarians or Older

Background and Objectives: The demand for permanent pacemaker (PPM) implantation for extremely old patients is increasing. Prior to implanting PPMs, life expectancy evaluation is essential but difficult. We aimed to develop and validate a scoring system for all-cause mortality risk stratification prior to PPM implantation in patients aged ≥80. Materials and Methods: A total of 210 patients aged ≥80 who received PPM implantation were included. Multivariable analysis was performed to assess the effects of different variables on all-cause mortality in a derivation cohort (n = 100). We developed the MELODY score for stratifying all-cause mortality prior to PPM implantation and tested the scoring system in a validation cohort (n = 102). Results: After 4.0 ± 2.7 years of follow-up, 54 patients (54%) had died. The 0.5-, 1- and 2-year all-cause mortality rates were 7%, 10% and 24%, respectively. The MELODY score based on body mass index <21 kg/m2 (HR: 2.21, 95% CI: 1.06-4.61), estimated glomerular filtration rate <30 mL/min/1.73 m2 (3.35, 1.77-6.35), length of hospitalization before PPM implantation >7 days (1.87, 1.02-3.43) and dyspnea as the major presenting symptom (1.90, 1.03-3.50) successfully distinguished patients at high risk of mortality. Patients with MELODY scores ≥3 had a higher risk of mortality compared to those with MELODY scores <3 (8.49, 4.24-17.00). The areas under the receiver operating characteristic curves in predicting 0.5, 1 and 2 years mortality rates were 0.86, 0.81 and 0.74, respectively. The predictive value of the model was confirmed in a validation cohort. Conclusions: The novel scoring system is a simple and effective tool for all-cause mortality risk stratification prior to PPM implantation in patients aged ≥80.

Prevalence of depression and its association with quality of life in patients after pacemaker implantation during the COVID-19 pandemic: A network analysis

Background

This study was designed to investigate the prevalence and predictors of depression in patients after pacemaker implantation during the COVID-19 pandemic in addition to identifying specific depressive symptoms associated with quality of life (QOL) using network analysis (NA).

Methods

This cross-sectional, observational study was conducted in China between July 1, 2021, and May 17, 2022. Descriptive analysis was used to calculate depression prevalence. Univariate analyses were used to compare differences in demographic and clinical characteristics between depressed and non-depressed patients following pacemaker implantation. Binary logistic regression analysis was used to assess factors independently associated with depression. Network analysis “expected influence,” and flow function indexes were used to identify symptoms central to the depression network of the sample and depressive symptoms that were directly associated with QOL, respectively. Network stability was examined using a case-dropping bootstrap procedure.

Results

In total, 206 patients implanted with a pacemaker met the study entry criteria and completed the assessment. The overall prevalence of depression (PHQ-9 total score ≥ 5) was 39.92% [95% confidence interval (CI) = 29.37−42.47%]. A binary logistic regression analysis revealed that patients with depression were more likely to report a poor health status (p = 0.031), severe anxiety symptoms (p &lt; 0.001), and fatigue (p &lt; 0.001). In the network model for depression, “Sad mood,” “Poor Energy,” and “Guilt” were the most influential symptoms. “Fatigue” had the strongest negative association with QOL, followed by “Sad mood” and “Appetite”.

Conclusion

Depression is common among patients having undergone pacemaker implantation during the COVID-19 pandemic. Anxiety, central symptoms of depression (i.e., “Sad mood”, “Poor Energy”, and “Guilt”) and depressive symptoms linked to QOL (i.e., “Sad mood”, “Appetite”, and “Fatigue”) identified in this study are promising targets for interventions and preventive measures for depression in patients who have undergone pacemaker implants.

Cardiac variables associated with atrial fibrillation occurrence and mortality in octogenarians implanted with dual chamber permanent pacemakers

BACKGROUND

There is a dearth of data on the predictors of atrial fibrillation (AF) and the association between AF and long-term mortality in octogenarians with dual-chamber permanent pacemakers (PPM). We investigate the occurrence of AF and whether it is associated with overall mortality among octogenarians with dual-chamber PPM implants.

METHODS

Three hundred and fifty-four patients with PPM implants were divided into two groups based on their long-term survival status. Baseline characteristics, laboratory variables, and echocardiographic variables were then compared between the groups, and independent predictors of the long-term incidence of AF and mortality were determined.

RESULTS

Multivariable Cox regression analysis performed after adjusting for the parameters in univariable analysis revealed that diabetes, urea levels, albumin levels, paced QRS duration, and the frequency of atrial high-rate episodes (AHREs) were independently associated with a long-term risk of AF in octogenarians after having dual chamber PPMs implanted. The left ventricular (LV) ejection fraction, left atrial (LA) anteroposterior diameter, and AHRE + AF (HR 1.498, 95%CI 1.003-2.237, p = 0.048) were independent risk factors for the long-term mortality in octogenarians receiving dual-chamber PPMs implants.

CONCLUSION

The occurrence of AF following dual-chamber PPM implantation is a significant prognostic factor in octogenarian patients.

Prognostic value of serum albumin for long-term mortality in patients with dual-chamber permanent pacemakers

Background: This investigation aims to examine the prognostic utility of albumin concentrations for long-term all-cause mortality in patients undergoing permanent pacemaker implantation. Methods: A total of 1798 patients who received permanent pacemaker implantation were divided into quartiles according to serum albumin concentrations. The significance of albumin in predicting long-term mortality was compared in these quartiles. Results: There was a higher rate of long-term mortality in the Q4 group compared with the Q1-3 groups (49.9 vs 15.8%). The risk of long-term mortality in the Q4 group was 3.6-times higher compared with the Q1-3 groups after adjustment for confounders. Conclusion: Serum albumin level at the time of device implantation has great value when assessing long-term mortality in patients with permanent pacemakers.

Long-Term, Single-Centre Observation of Patients with Cardiac Implantable Electronic Devices

Background and Objectives: Electrotherapy is a valuable treatment method for patients with heart rhythm disturbances. There are very few observations of long-term patients treated with these techniques. There is a particular lack of this type of study conducted in Eastern European countries. The aim of this single-centre analysis was to evaluate the long-term survival (from 2010 to 2018) of patients treated with electrotherapy devices, taking into account clinical factors facilitating the prognosis of these patients. Materials and Methods: The patients (N = 2071) subsequently included in the study were subjected to the implementation or replacement of cardiac pacemakers. The medical records of all the patients were analysed. Data concerning death, made available by the State Systems Department of the Ministry of Administration and Digitization, were used. Results: The patients with VVI pacemakers had the worst prognosis after the replacement of the devices. Male patients had a worse prognosis, regardless of the kind of device implanted. Advanced atrioventricular conduction disturbances, chronic kidney disease, and hypothyroidism with reduced left ventricular ejection fraction were among the most significant coexisting diseases. Conclusions: The long-term prognosis of patients under different forms of electrotherapy remains poor. Despite the more straightforward technique, a single-chamber device (VVI/AAI) or generator replacement leads to the worst prognosis. The complexity of the clinical picture that stems from coexisting diseases and advanced age is of the utmost importance.

Predictors of outcomes in hospitalized patients undergoing pacemaker insertion: Analysis from the national inpatient database (2016-2017)

BACKGROUND

Pacemaker implantation in the U.S. is rising due to an aging population. The aim of this analysis was to identify risk factors associated with increased mortality and complications in hospitalized patients requiring pacemaker implantation.

METHODS

We performed a retrospective analysis using the National Inpatient Sample database, identifying hospitalized patients who underwent pacemaker implantation using International Classification of Disease, Tenth Revision, Clinical Modification codes. Independent predictors of inpatient mortality were identified using multivariate logistic regression analysis.

RESULTS

There were 242,980 hospitalizations with pacemaker implantation during 2016 and 2017. The most frequently encountered indications for hospitalizations involving pacemaker insertion included sick sinus syndrome (SSS) (27.60%), complete atrioventricular (AV) block (21.57%), and second-degree AV block (7.83%). Chronic liver disease was associated with the highest adjusted odds of inpatient mortality (aOR = 5.76, 95% CI: 4.46 to 7.44, p < .001). Comorbid anemia had the highest statistically significant adjusted odds ratio (aOR) for predictors of post-procedural cardiac complications (aOR = 3.17, 95% CI: 2.81 to 3.58, p < .001). Mortality in hospitalized patients needing pacemaker implantation was 1.05%. About 3.36% of hospitalizations developed post procedural circulatory complications (PPCC), 2.45% developed sepsis, and 1.84% developed mechanical complications of cardiac electronic devices.

CONCLUSIONS

We identified several predictors of inpatient mortality in hospitalized patients undergoing pacemaker implantation, including chronic liver disease, protein-calorie malnutrition, chronic heart failure, anemia, and history of malignancy. Anemia, chronic liver disease, and congestive heart failure were independent predictors of adverse outcomes in such patients.

[Interventional cardiology in the elderly, at the time of TAVI and left atrial appendage occlusion]

Interventional cardiology is increasingly being offered to frail elderly people thanks to significant technical progress. Transcatheter aortic valve implantation allows the treatment of aortic stenosis by implanting an aortic bioprosthesis through a catheter, without surgery. The left atrial appendage occlusion limits the risk of ischemic stroke in patients with atrial fibrillation who have a contraindication to anticoagulants. These procedures remain invasive and must be proposed after multidisciplinary consultation.