Acute complications of permanent pacemaker implantation: their financial implication and relation to volume and operator experience

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.

National Tunisian Study of Cardiac Implantable Electronic Devices: Design and Protocol for a Nationwide Multicenter Prospective Observational Study

BACKGROUND

In Tunisia, the number of cardiac implantable electronic devices (CIEDs) is increasing, owing to the increase in patient life expectancy and expanding indications. Despite their life-saving potential and a significant reduction in population morbidity and mortality, their increased numbers have been associated with the development of multiple early and late complications related to vascular access, pockets, leads, or patient characteristics.

OBJECTIVE

The study aims to identify the rate, type, and predictors of complications occurring within the first year after CIED implantation. It also aims to describe the demographic and epidemiological characteristics of a nationwide sample of patients with CIED in Tunisia. Additionally, the study will evaluate the extent to which Tunisian electrophysiologists follow international guidelines for cardiac pacing and sudden cardiac death prevention.

METHODS

The Tunisian National Study of Cardiac Implantable Electronic Devices (NATURE-CIED) is a national, multicenter, prospectively monitored study that includes consecutive patients who underwent primary CIED implantation, generator replacement, and upgrade procedure. Patients were enrolled between January 18, 2021, and February 18, 2022, at all Tunisian public and private CIED implantation centers that agreed to participate in the study. All enrolled patients entered a 1-year follow-up period, with 4 consecutive visits at 1, 3, 6, and 12 months after CIED implantation. The collected data are recorded electronically on the clinical suite platform (DACIMA Clinical Suite).

RESULTS

The study started on January 18, 2021, and concluded on February 18, 2023. In total, 27 cardiologists actively participated in data collection. Over this period, 1500 patients were enrolled in the study consecutively. The mean age of the patients was 70.1 (SD 15.2) years, with a sex ratio of 1:15. Nine hundred (60%) patients were from the public sector, while 600 (40%) patients were from the private sector. A total of 1298 (86.3%) patients received a conventional pacemaker and 75 (5%) patients received a biventricular pacemaker (CRT-P). Implantable cardioverter defibrillators were implanted in 127 (8.5%) patients. Of these patients, 45 (3%) underwent CRT-D implantation.

CONCLUSIONS

This study will establish the most extensive contemporary longitudinal cohort of patients undergoing CIED implantation in Tunisia, presenting a significant opportunity for real-world clinical epidemiology. It will address a crucial gap in the management of patients during the perioperative phase and follow-up, enabling the identification of individuals at particularly high risk of complications for optimal care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05361759; https://classic.clinicaltrials.gov/ct2/show/NCT05361759.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/47525.

Outcomes of a 24/7 service for urgent permanent pacemaker implantation

INTRODUCTION AND OBJECTIVES

Most of the complications associated with acute and symptomatic bradyarrhythmia (ASB) occur in the time from diagnosis to permanent pacemaker implantation (PPI). We aimed to evaluate the outcomes of an urgent 24/7 PPI service (PPI-24/7) for patients with ASB.

METHODS

A total of 664 patients undergoing first-time PPI for ASB were prospectively assessed during 2 periods of identical length (18 months): 341 patients who underwent the procedure during working hours only (PPI-WH), and 323 patients who underwent the procedure after the implementation of the PPI-24/7 service. The primary safety endpoint was established as the cumulative 180-day incidence of complications related to the index arrhythmia and device implant. The primary efficacy endpoint was determined as the average number of hospital stays per patient.

RESULTS

The PPI-24/7 period was associated with a significant shortening of the time from diagnosis to implantation (median [interquartile range]): 3hours [2-6] vs 16 [5-21]). The cumulative incidence of patients with complications at 180 days was lower in the PPI-24/7 period: 9% vs 17% (adjusted odds ratio, 0.5; P=.002), due to a significant reduction in preimplant complications: 2.5% vs 12% (P <.001). The average number of hospital stays was reduced by 2 per patient in the PPI-24/7 period (nonparametric P <.001). PPI-24/7 implants performed outside working hours (n=178) were safe, with a 180-day cumulative incidence in procedure-related complications of 3.9%.

CONCLUSIONS

Among patients with ASB, PPI-24/7 was associated with a significant reduction in patient morbidity and efficient hospital resource use.

Early real-world implant experience with a helix-fixation ventricular leadless pacemaker

BACKGROUND

Roughly one in six patients receiving conventional transvenous pacemaker systems experience significant complications within 1 year of implant, mainly due to the transvenous lead and subcutaneous pocket. A new helix-fixation single-chamber ventricular leadless pacemaker (LP) system capable of pre-deployment exploratory electrical mapping is commercially available. Such an LP may mitigate complications while streamlining the implantation. In this study, the initial real-world implant experience of the helix-fixation LP was evaluated following its commercial release.

METHODS

In patients indicated for single-chamber right ventricular pacing, helix-fixation Aveir VR LPs (Abbott, Abbott Park, IL) were implanted using the dedicated loading tool, introducer, and delivery catheter. Implant procedural characteristics, electrical parameters, and any 30-day procedure-related adverse events of consecutive implant attempts were retrospectively evaluated.

RESULTS

A total of 167 patients with Class I indication for permanent pacing received implants in four North American centers (57% male, 70 years old). Pre-fixation electrical mapping of potential sites allowed repositioning to be avoided in 95.7% of patients. Median [interquartile range] LP procedure and fluoroscopy durations were 25.5 min [20.0, 35.0] and 5.7 min [4.0, 9.2], respectively. Pacing capture threshold, sensed R-wave amplitude, and impedance were 0.8 V [0.5, 1.3], 9.0 mV [6.0, 12.0], and 705 Ω [550, 910], respectively. Implantation was successful in 98.8% of patients, with 98.2% free from acute adverse events.

CONCLUSIONS

The initial, real-world experience of the helix-fixation ventricular leadless pacemaker demonstrated safe and efficient implantation with minimal repositioning, viable electrical metrics, and limited acute complications.

Trends in the 30-year span of noninfectious cardiovascular implantable electronic device complications in Olmsted County

Background

Cardiac implantable electronic devices (CIEDs), such as permanent pacemakers, implantable cardioverter-defibrillators, and cardiac resynchronization therapy devices, alleviate morbidity and mortality in various diseases. There is a paucity of real-world data on CIED complications and trends.

Objectives

We sought to describe trends in noninfectious CIED complications over the past 3 decades in Olmsted County.

Methods

The Rochester Epidemiology Project is a medical records linkage system comprising records of over 500,000 residents of Olmsted County from 1966 to present. CIED implantations between 1988 and 2018 were determined. Trends in noninfectious complications within 30 days of implantation were analyzed.

Results

A total of 157 (6.2%) of 2536 patients who received CIED experienced device complications. A total of 2.7% of the implants had major complications requiring intervention. Lead dislodgement was the most common (2.8%), followed by hematoma (1.7%). Complications went up from 1988 to 2005, and then showed a downtrend until 2018, driven by a decline in hematomas in the last decade (P < .01). Those with complications were more likely to have prosthetic valves. Obesity appeared to have a protective effect in a multivariate regression model. The mean Charlson comorbidity index has trended up over the 30 years.

Conclusion

Our study describes a real-world trend of CIED complications over 3 decades. Lead dislodgements and hematomas were the most common complications. Complications have declined over the last decade due to safer practices and a better understanding of anticoagulant management.

Assessment of Trend, Indication, Complications, and Outcomes of Pacemaker Implantation in Adult Patients at Tertiary Hospital of Ethiopia: Retrospective Follow Up Study

Background

A pacemaker is a device implanted in the chest to help people with symptomatic bradycardia and life-threatening irregular rhythm. However, it is also associated with many complications. Therefore, this study evaluated pacemaker-related complications and factors associated with them, as there is little data on pacemaker-related complications in sub-Saharan Africa and Ethiopia.

Methods

The study was conducted on 118 patients over 18 years old who had pacemakers implanted between 2017 and 2022 at Tikur Anbessa Comprehensive Specialized Hospital in Addis Ababa, Ethiopia who were reviewed by the authors from September 2022 to December 2022. Sociodemographic factors, clinical characteristics, and complications data were extracted using a structured questionnaire by retrospective review of patient records. The chi-square test or Fisher's exact test was performed to evaluate factors associated with complications.

Results

The median age of patients was 60.5 years (IQR = 15 years), with men accounting for 50.8% of patients. Hypertension was the most common comorbidity (64.2%). Symptomatic grade 3 AV block was the most common indication (78.8%) for pacemaker implantation. With a mean follow-up of 3.92 ± 1.94 years, 15.3% of patients had complications. Pneumothorax, pocket site infection, and lead dislodgement were the most common complications occurring in 2.54% of patients each. Patient age during surgery (p-value = 0.02), patient gender (p-value = 0.04), pacemaker implanting team (p-value = 0.01), and adherence to follow-up (p-value = 0.04) are related to pacemakers-related complications.

Conclusion

Pacemaker implantation is associated with many complications. Pneumothorax, pacemaker pocket infection, and lead dislodgement were the most common complications. Patient age at pacemaker implantation, patient gender, pacemaker implanting team, and follow-up compliance were factors associated with pacemaker-related complications. Skill development through specialized training and compliance counseling may improve outcomes for patients who have complications related to pacemaker implanting team and poor adherence to follow.

Relationship between ICD implantation volume and treatment parameters of patients receiving an ICD with remote monitoring

BACKGROUND

Both highly specialized heart centres and less specialized hospitals care for patients with implantable ICDs/CRT-Ds with remote monitoring.

OBJECTIVE

To investigate potential differences in patient treatment according to centre's ICD implantation volume.

METHODS

Based on their 2012 ICD/CRT-D implantation volume, centres enrolled in the NORDIC ICD trial in Germany were assigned to one of three groups: high- (HV, n= 345), medium- (MV, n= 340) or low-volume (LV, n= 189).

RESULTS

The HV-centres had a significant higher CRT-D proportion (41.7%; LV: 36.5%; MV: 23.2%; P𝑔𝑙𝑜𝑏𝑎𝑙< 0.001), significant shorter median procedure duration (49 min; MV: 58 min; LV: 60 min; P𝑔𝑙𝑜𝑏𝑎𝑙< 0.001) but significant longer median hospital stay (4 days; MV and LV: 3 days; P𝑔𝑙𝑜𝑏𝑎𝑙< 0.001) compared to MV- and LV-centres. The X-ray exposure was shorter in MV/HV-centres (MV: 3.4 min; HV: 3.6 min; LV: 5.5 min; P𝑔𝑙𝑜𝑏𝑎𝑙< 0.001). Only 3.5% (LV: 2.6%; HV: 3.5%; MV: 4.1%) patients received at least one delivered inappropriate shock and 2.5% (HV: 2.0%; LV: 2.6%; MV: 2.9%) patients had withheld inappropriate ICD shocks without subsequent inappropriate shock delivery within 24.5 months of median follow-up.

CONCLUSION

Implantation volume-dependent differences were observed in the device selection, procedure duration and x-ray exposure duration. Remote monitoring in combination with adequate response pattern prevented imminent inappropriate shocks in all three groups.

Trends in the 30-year span of Noninfectious Cardiovascular Implantable Electronic Device Complications in Olmsted County

Background

Cardiovascular implantable electronic devices (CIEDs) such as permanent pacemakers, implantable cardioverter-defibrillators, and cardiac resynchronization therapy devices alleviate morbidity and mortality in various diseases. There is a paucity of real-world data on CIED complications and trends.

Objectives

Describe trends in noninfectious CIED complications over the past three decades in Olmsted County.

Methods

The Rochester Epidemiology Project is a medical records linkage system comprising records of over 500,000 residents of Olmsted County from 1966-current. CIED implants between 1988-2018 were determined. Trends in noninfectious complications within 30 days of implant were analyzed.

Results

175 out of 2536 (6.9%) patients who received CIED experienced device complications. 3.8% of the implants had major complications requiring intervention. Lead dislodgement was the most common (2.9%), followed by hematoma (2.1%). Complications went up from 1988 to 2005, then showed a downtrend until 2018, driven by a decline in hematomas in the last decade (p<0.01). Those with complications were more likely to have prosthetic valves. Obesity appeared to have a protective effect in a multivariate regression model. The mean Charlson comorbidity score has trended up over the 30 years.

Conclusions

Our study describes a real-world trend of CIED complications over three decades. Lead dislodgements and hematomas were the most common complications. Complications have declined over the last decade due to safer practices and a better understanding of anticoagulant management.

Leadless Cardiac Pacing: New Horizons

Since the introduction of transvenous cardiac pacing leads, pacemaker system design has remained similar for several decades. Progressive miniaturisation of electronic circuitry and batteries has enabled a smaller, single pacing unit comprising the intracardiac electrodes, generator and computer. This review explores the development of leadless pacing, the clinical trials comparing leadless to transvenous pacing in addition to the future developments of multi-chamber leadless pacing.

Sex differences in rates of permanent pacemaker implantation and in-hospital complications: A statewide cohort study of over 7 million persons from 2009–2018

Background

Whether a bias exists in the implantation of permanent pacemakers (PPI) and complications according to sex and age in the Australian population is unclear.

Hypothesis

Population rate of PPI and its complications differed between men and women.

Methods

We examined the prevalence of PPI from January-2009 to December-2018 from datasets held by the New South Wales (NSW) Centre-for-Health-Record-Linkage, including patient’s characteristics and in-hospital complications. All analysis was stratified by sex and age by decade.

Results

A total of 28,714 admissions involved PPI (40% women). The mean PPI rate (±standard-deviation) and median age (interquartile range) was 2,871±242 per-annum and 80yrs (73-86yrs), respectively. At the same time-period, the mean NSW population size was 7,487,393±315,505 persons (50% women; n = 3,773,756±334,912). The mean annual age-adjusted rate of PPI was 125.5±11.6 per-100,000-men, compared to 63.4±14.3 per-100,000-women (P<0.01). The mean annual rate of PPI increased from 2009–2017 by 0.9±3.3% in men, compared to 0.4±4.4% in women (P<0.01) suggesting a widening disparity. Total non-fatal in-hospital complications was higher in women compared to men (8.2% vs 6.6%, P<0.01), and this persisted throughout study period even after adjusting for multiple covariates. Overall, in-hospital mortality was low (0.73%) and similar between sexes.

Conclusion

In a statewide Australian population exceeding 7 million, PPI rates were consistently nearly two-fold higher for men compared to women over 10-years, with an apparently widening disparity, that was not explained by age. Overall complication rates were higher in women. Future studies should examine the aetiology behind this disparity in PPI rates, as well as its complications.

Sex-related differences regarding cephalic vein lead access for CIEDs implantation

Background

Minimally invasive and safe central venous access is imperative for lead insertion of cardiac implantable electronic devices (CIEDs). The purpose of this trial was to explore and compare the usability of the cephalic vein (CV) between both sexes.

Methods and results

This single-center prospective study included 102 consecutive patients in a period of six months. Pre-procedural contrast-enhanced venographic images of the upper arm were performed in all included patients. Our attention was focused on comparing several morpho-anatomical CV characteristics such as venous diameter, presence of valves and angle of entrance of the CV into the subclavian vein (SV). Study results concerning the CV morpho-anatomical differences were more favorable regarding the female patient group, with significant differences in CV diameter (p-0.030). There was also a difference in favor of the female group regarding the favorable CV angle of entrance into the SV, found in the 61.7% versus 54.4% in the male patient group. The comparison of usability of the CV and CVC technique was explored by comparing the number of leads inserted through the CV in both sexes. Two leads were implanted in 11.7% in the female group versus 5.8% in the male group, and 0 leads through the CV in 38.2% of the female patients versus 50% of male group.

Conclusion

Female patients have more favorable cephalic vein morpho-anatomical futures and better usability for lead placement than male patients.

Leadless pacemakers: A review of current data and future directions

Leadless pacemakers (LPs) have revolutionized the field of pacing by miniaturizing pacemakers and rendering them completelty intracardiac, hence reducing complications related to pacemaker pockets and transvenous leads. However, first generation LPs appear to be associated with a higher rate of myocardial perforation as compared to transvenous pacemakers (TV-PPM). Currently, LPs are predominantly designed to pace the right ventricle with no LPs that provide atrial or biventricular pacing. In this article, we review the available data on LPs while advocating for the need for a randomized controlled trial comparing LPs to TV-PPMs. In addition, we review the future directions of leadless devices.

Inadvertent Right Ventricle Perforation by Temporary Pacemaker Lead: A Case Report Requiring Surgical Exploration

Right ventricle perforation by pacemaker lead is rare but a life-threatening complication. It may present acutely within few hours of pacemaker implantation as hemopericardium, dreaded cardiac tamponade, leading to acute hemodynamic deterioration; even death, if not address immediately. At times, it presents gradually with progressive decline in hemodynamic and requires surgical exploration.

The authors report a case of 51-year old female whose hemodynamic worsens gradually after temporary pacemaker implantation, requiring surgical exploration.

Upper extremity dysfunctions in patients with cardiac implantable electronic devices: a systematic review

Background/Aims

The prevalence of cardiac implantable electronic devices has risen considerably during recent years. This has revolutionised the treatment of cardiac arrhythmias, which in turn reduced the incidence of sudden cardiac death. There are several complications associated with cardiac implantable electronic device implantation. Upper extremity dysfunction is one of the complications associated with this procedure and it should be addressed, since it can affect activities of daily living. This systematic review analysed the prevailing evidence pertaining to the common upper extremity dysfunctions associated with receiving a cardiac implantable electronic device.

Methods

A comprehensive literature search was conducted using PubMed, Cochrane Central Register of Controlled Trials, EMBASE (through Cochrane) and Google Scholar for original research published in the English language. The Rayyan QCRI web application was used for study selection and the decision-making process. PRISMA guidelines were used to conduct and report this review. The methodological quality of the included studies was appraised using the Newcastle–Ottawa Scale and Joanna Briggs Institute critical appraisal tool for analytic cross-sectional studies and case reports.

Results

This systematic review included eight studies with a total of 696 participants. The most common upper extremity dysfunctions associated with receiving a cardiac implantable electronic device were pain and limitation of shoulder range of motion. Limitation of range of motion could be persisted even in the long term after having a cardiac implantable electronic device implanted.

Conclusions

Contributing factors of upper extremity dysfunctions included size of the device, pectoral site of implantation and upper extremity immobilisation practices. Upper extremity dysfunction is an overlooked complication, as it received a relatively low priority, although it may negatively impact quality of life.

European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)

Pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy devices are potentially life-saving treatments for a number of cardiac conditions, but are not without risk. Most concerning is the risk of a cardiac implantable electronic device (CIED) infection, which is associated with significant morbidity, increased hospitalizations, reduced survival, and increased healthcare costs. Recommended preventive strategies such as administration of intravenous antibiotics before implantation are well recognized. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, anti-bacterial envelopes, prolonged antibiotics post-implantation, and others. Guidance on whether to use novel device alternatives expected to be less prone to infections and novel oral anticoagulants is also limited, as are definitions on minimum quality requirements for centres and operators and volumes. Moreover, an international consensus document on management of CIED infections is lacking. The recognition of these issues, the dissemination of results from important randomized trials focusing on prevention of CIED infections, and observed divergences in managing device-related infections as found in an European Heart Rhythm Association worldwide survey, provided a strong incentive for a 2019 International State-of-the-art Consensus document on risk assessment, prevention, diagnosis, and treatment of CIED infections.

European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)

Pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy devices are potentially life-saving treatments for a number of cardiac conditions, but are not without risk. Most concerning is the risk of a cardiac implantable electronic device (CIED) infection, which is associated with significant morbidity, increased hospitalizations, reduced survival, and increased healthcare costs. Recommended preventive strategies such as administration of intravenous antibiotics before implantation are well recognized. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, anti-bacterial envelopes, prolonged antibiotics post-implantation, and others. Guidance on whether to use novel device alternatives expected to be less prone to infections and novel oral anticoagulants is also limited, as are definitions on minimum quality requirements for centres and operators and volumes. Moreover, an international consensus document on management of CIED infections is lacking. The recognition of these issues, the dissemination of results from important randomized trials focusing on prevention of CIED infections, and observed divergences in managing device-related infections as found in an European Heart Rhythm Association worldwide survey, provided a strong incentive for a 2019 International State-of-the-art Consensus document on risk assessment, prevention, diagnosis, and treatment of CIED infections.

European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID), and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)

Pacemakers, implantable cardiac defibrillators, and cardiac resynchronization therapy devices are potentially lifesaving treatments for a number of cardiac conditions but are not without risk. Most concerning is the risk of a cardiac implantable electronic device (CIED) infection, which is associated with significant morbidity, increased hospitalizations, reduced survival, and increased health care costs. Recommended preventive strategies such as administration of intravenous antibiotics before implantation are well-recognized. Uncertainties have remained about the role of various preventive, diagnostic, and treatment measures such as skin antiseptics, pocket antibiotic solutions, antibacterial envelopes, prolonged antibiotics post-implantation, and others. When compared with previous guidelines or consensus statements, the present consensus document gives guidance on the use of novel device alternatives, novel oral anticoagulants, antibacterial envelopes, prolonged antibiotics post-implantation, as well as definitions on minimum quality requirements for centres and operators and volumes. The recognition that an international consensus document focused on management of CIED infections is lacking, the dissemination of results from new important randomized trials focusing on prevention of CIED infections, and observed divergences in managing device-related infections as found in an European Heart Rhythm Association worldwide survey, provided a strong incentive for a Novel 2019 International State-of-the-art Consensus document on risk assessment, prevention, diagnosis, and treatment of CIED infections.

Cephalic vein access by modified Seldinger technique for lead implantations

BACKGROUND

Venous access for cardiac implantable electronic devices (CIED) is commonly performed by cephalic venous cut down, or axillary or subclavian vein puncture. The latter technique carries a risk of complications such as pneumothorax or lead crush. Cephalic venous cut down is free of these complications but often less successful due to technical difficulties. We report a highly successful, simplified cephalic venous access with a modified Seldinger technique.

METHODS

We prospectively studied 221 patients undergoing de novo implantation of a one, two, or three lead device system performed over a 1-year period at our center, and assessed the efficacy of the cephalic vein access including the number of leads successfully placed for each procedure.

RESULTS

In 83% of patients undergoing CIED implantation, a suitable cephalic vein was present. In respectively 98% and 99% of patients undergoing single- or dual-chamber CIED implantation, lead placement could be performed exclusively via the cephalic vein and in 72% of cardiac resynchronization therapy implants, all three leads were placed via cephalic access.

CONCLUSION

A novel, technically simple cephalic venous catheterization technique provides high success rates for any CIED lead implantation.

Strategies to Promote Long-Term Cardiac Implant Site Health

In the past several decades there has been a continuous growth in the field of cardiac implantable electronic devices (CIED) implantation procedures as well as their technological development. CIEDs utilize transvenous leads that are introduced into the heart via the axillary, subclavian, or cephalic veins, as well as a devices generator that is implanted in a subcutaneous pocket, typically in the pre-pectoral region. Despite this significant improvement, complication rates range from 1-6% with current implant tools and techniques. In this review we will discuss the three central parts of the CIED implantation procedure, their impact on implantation site, infections, and possibilities for its prevention.

Unscheduled Emergency Visits after Cardiac Devices Implantation: Comparison between Cardioverter Defibrillators and Cardiac Resynchronization Therapy Devices in less than one year of Follow Up

BACKGROUND

The use of Cardiovascular Implantable Electronic Devices (CIED), such as the Implantable Cardioverter Defibrillator (ICD) and Cardiac Resynchronization Therapy (CRT), is increasing. The number of leads may vary according to the device. Lead placement in the left ventricle increases surgical time and may be associated with greater morbidity after hospital discharge, an event that is often confused with the underlying disease severity.

OBJECTIVE

To evaluate the rate of unscheduled emergency hospitalizations and death after implantable device surgery stratified by the type of device.

METHODS

Prospective cohort study of 199 patients submitted to cardiac device implantation. The groups were stratified according to the type of device: ICD group (n = 124) and CRT group (n = 75). Probability estimates were analyzed by the Kaplan-Meier method according to the outcome. A value of p < 0.05 was considered significant in the statistical analyses.

RESULTS

Most of the sample comprised male patients (71.9%), with a mean age of 61.1 ± 14.2. Left ventricular ejection fraction was similar between the groups (CRT 37.4 ± 18.1 vs. ICD 39.1 ± 17.0, p = 0.532). The rate of unscheduled visits to the emergency unit related to the device was 4.8% in the ICD group and 10.6% in the CRT group (p = 0.20). The probability of device-related survival of the variable "death" was different between the groups (p = 0.008).

CONCLUSIONS

Patients after CRT implantation show a higher probability of mortality after surgery at a follow-up of less than 1 year. The rate of unscheduled hospital visits, related or not to the implant, does not differ between the groups.

Safety of Permanent Pacemaker Implantation: A Prospective Study

Although pacemaker implantation is considered to be low risk, it is not exempt from complications and technical failures during the procedure, both in the short and long term, and the complications that such patients may present remain unknown. The aim has been to analyze the complication rates associated with permanent pacing and to identify if these differ between patients with or without previous antithrombotic therapy. We used a prospective, single center, observational study of 310 adult patients with indications of permanent pacing. They were hospitalized from 1 January to 31 December 2014 and followed up for 6 months after the pacemaker implant. The participants were distributed into two groups according to the antithrombotic therapy prior to the implant. The most frequent major complications were pneumothorax (3.87%) and lead dislodgement (8.39%), while superficial phlebitis (12.90%) and uncomplicated hematomas (22.58%) were presented as the most recurrent minor complications. Hematomas were the most frequent minor complication in the antithrombotic therapy cohort, and shoulder pain was reported as the most recurrent minor complication in the non-exposed group. Finding out about complications in pacemaker implants enables a complete view of the process, and hence the prioritization of actions aimed at improving safety and reducing associated risks.

Vein Management for Cardiac Device Implantation

Transvenous approaches for pacemaker and defibrillator lead insertion offer numerous advantages over epicardial techniques. Although the cephalic, axillary, and subclavian veins are most commonly used in clinical practice, they each offer their own set of advantages and disadvantages that leave their usage dependent on patient anatomy and physician preference. Alternative methods using the upper and lower venous circulation have been described when these veins are not available or practical for lead insertion. Until current technology is superseded by leadless pacing systems, the search for the optimal lead insertion technique continues.

Scoring System Assessment of Cephalic Vein Access for Device Implantation

The purpose of this study was to explore the usability of the cephalic vein (CV) for cardiac implantable electronic device (CIED) lead access by applying a scoring system to assess the venous anatomy. This prospective, single-center study included 100 consecutive patients who underwent CIED implantation within a period of one year. Contrast-enhanced venography images were obtained for every patient, focused on the CV, "T-junction," and the subclavian/axillary veins (SV/AVs). Though careful examination of the images, an angle, valves, diameter, noncollateral (AVDnC) score was constructed and used to aid in choosing a CV or SV/AV access approach; in all cases, however, the preferred approach was CV independent of the AVDnC score result obtained. Upon use of the scoring system, the majority of patients (54%) had type A score result (≥ 3), indicating a favorable anatomy for CV access. In 48 of these patients, the CV was used for the implantation of at least one lead. The remaining 46 (46%) patients had type B score result (≤ 2). In 41 patients from this group, SV/AV access was used for lead implantation and, in five patients, CV access was used. The number of leads introduced through the CV was associated with larger score and the operator's experience. In conclusion, in more than 50% of patients, at least one lead could be introduced through the CV. The scoring system used herein can simplify the choice between CV and SV/AV access and could eventually increase the efficiency and safety of the procedure, especially when less experienced implanters are involved.

Living with a pacemaker: patient-reported outcome of a pacemaker system

Background

The aim of this study was to assess among pacemaker patients their overall satisfaction with the pacemaker system, pain, soreness/discomfort, cosmetic results, restrictions due to impaired movement of the shoulder/arm/chest, related sleep disturbances, and concern about possible device malfunction.

Methods

The seven-item questionnaire was mailed to patients from a single center who had a pacemaker implant or replacement between 2006 and 2016. A higher score indicated worse outcome on a visual analog scale (VAS) of 0–100 mm.

Results

The response rate was 75.5% and 342 questionniares were analyzed. Median age of respondents was 77.6 years and 57.0% were males. In total, 65 complications requiring surgery (10 pocket corrections (2.9%), 5 in females) occurred during a median follow-up of 5.6 years.The distribution of the primary outcome had a median score of 5 while the 75th percentile was 13. Cosmetic appearance was significantly associated with reoperation (but not other variables). Overall scores for men and women were 5 vs. 6, respectively, which achieved significance (p = 0.042). Median ratings of pain, soreness/discomfort, cosmetic appearance, range of motion, sleep, and concern about device malfunction were all ≤5. Females reported worse outcomes for all questions, except for cosmetic results and concern about malfunction.

Conclusions

The vast majority of patients report excellent overall satisfaction with the pacemaker system, and are not affected by pain, soreness/discomfort, or concern about device malfunction. They also reported favourable outcomes with respect to cosmetic results, shoulder movement, and sleep. However, some patients underwent a surgical correction of the pacemaker pocket.

A novel technique for ligation of the cephalic vein reduces hemorrhaging during a two-in-one insertion of dual cardiac device leads

The cutdown technique for the cephalic vein is a common access route for transvenous cardiac device leads (TVLs), and sometimes one cephalic vein can accomodate two TVLs. We examined a novel ligation technique to balance the hemostasis and lead maneuverability for this two-in-one insertion. A total of 22 patients scheduled for cardiac device implantations with two or more leads were enrolled. The ipsilateral cephalic vein was identified for inserting the TVLs with a cutdown. If two TVLs could be introduced into one cephalic vein, hemostasis was established by ligating the venous wall between the TVLs. We measured the amount of hemorrhaging per minute and the operators assessed the lead maneuverability before and after the ligation. We successfully implanted cardiac devices in 15 patients (68%) with this novel method, whereas only one TVL could be introduced via the cephalic vein in 7 patients. As for the successful patients, hemorrhaging from the gap was significantly reduced (5.6 ± 7.3 to 0.41 ± 0.36g/min, p = 0.016) after the novel ligation. The lead maneuverability was well maintained so there was no difficulty placing the leads into the cardiac chambers in all cases. No major complications were observed. In the present study, the novel ligation method provided significant hemostasis as well as a preserved maneuverability. It could be an optional choice for insertion of multiple TVLs.

Efficacy of postoperative prophylactic antibiotics in reducing permanent pacemaker infections

BACKGROUND

Despite limited evidence, postoperative prophylactic antibiotics are often used in the setting of permanent pacemaker implantation or replacement. The aim of this study is to investigate the efficacy of postoperative antibiotics.

HYPOTHESIS

Postoperative prophylactic antibiotics may be not clinically useful.

METHODS

We recruited 367 consecutive patients undergoing permanent pacemaker implantation or generator replacement at a tertiary referral center. Baseline demographics, clinical characteristics, and procedure information were collected, and all patients received preoperative prophylactic antibiotics. Postoperative prophylactic antibiotics were administered at the discretion of the treating physician, and all patients were seen in follow-up every 3 to 6 months for an average follow-up period of 16 months. The primary endpoint was device-related infection.

RESULTS

A total of 110 patients were treated with preoperative antibiotics only (group 1), whereas 257 patients received both preoperative and postoperative antibiotics (group 2). After a mean follow-up period of 16 months, 1 patient in group 1 (0.9%) and 4 patients in group 2 (1.5%) experienced a device-related infection. There was no significant difference in the rate of infection between the 2 groups (P = 0.624). In the univariate analysis, only the age (60 ± 11 vs 75 ± 12 years, P < 0.001) was significantly different between the infected and noninfected groups. In the multivariate analysis, younger age was an independent risk factor for infective complications (odds ratio = 1.08, P = 0.016).

CONCLUSIONS

Patients treated with preoperative and postoperative antibiotics had a similar rate of infection as those treated with preoperative antibiotics alone. Further studies are needed to confirm these preliminary findings.

In-hospital complications after implantation of cardiac implantable electronic devices: Analysis of a national inpatient database in Japan

BACKGROUND

Complications after implantation of cardiac implantable electronic devices (CIEDs), including permanent pacemakers (PMs) and other CIEDs, are associated with increased patient mortality and healthcare costs. This study aimed to investigate overall complications after implantation of CIEDs, analyze the associated risk factors, and compare complications after PM implantation between hospitals that performed only PM implantations (PM-only hospitals) and hospitals that implanted other CIEDs, as well as PMs (all-CIED hospitals).

METHODS

Using the Japanese Diagnosis Procedure Combination database, we retrospectively collected data on inpatients who underwent CIED implantation from 1 July 2010 to 31 March 2014.

RESULTS

A total of 77,324 patients were identified, including 64,951 patients with PMs and 12,373 with other CIEDs. The overall incidences of in-hospital complications were 2.5% in patients with PMs and 2.1% in those with other CIEDs. The incidences of pocket infections, pocket problems, device- and lead-related problems, and sepsis were 0.9%, 0.5%, 0.4%, and 0.3%, respectively. The crude proportion of complications after PM implantation was higher in the PM-only hospitals than in the all-CIED hospitals (3.1% vs. 2.1%), but the multivariable logistic regression analysis showed no significant difference (odds ratio, 1.29; 95% confidence interval, 0.99-1.68).

CONCLUSION

After adjusting for patient backgrounds, the occurrence of complications after PM implantation was not significantly different between patients in PM-only hospitals and those in all-CIED hospitals.

Pacemaker leads and cardiac perforation

This case series highlights the rare but potentially life threatening complication of ventricular perforation caused by pacemaker leads and discusses appropriate investigations and management strategies.

Optimized Axillary Vein Technique versus Subclavian Vein Technique in Cardiovascular Implantable Electronic Device Implantation: A Randomized Controlled Study

BACKGROUND

The conventional venous access for cardiovascular implantable electronic device (CIED) is the subclavian vein, which is often accompanied by high complication rate. The aim of this study was to assess the efficacy and safety of optimized axillary vein technique.

METHODS

A total of 247 patients undergoing CIED implantation were included and assigned to the axillary vein group or the subclavian vein group randomly. Success rate of puncture and complications in the perioperative period and follow-ups were recorded.

RESULTS

The overall success rate (95.7% vs. 96.0%) and one-time success rate (68.4% vs. 66.1%) of punctures were similar between the two groups. In the subclavian vein group, pneumothorax occurred in three patients. The subclavian gaps of three patients were too tight to allow operation of the electrode lead. In contrast, there were no puncture-associated complications in the axillary vein group. In the patient follow-ups, two patients in the subclavian vein group had subclavian crush syndrome and both of them received lead replacement. The incidence of complications during the perioperative period and follow-ups of the axillary vein group and the subclavian vein group was 1.6% (2/125) and 8.2% (10/122), respectively (χ2 = 5.813, P = 0.016).

CONCLUSION

Optimized axillary vein technique may be superior to the conventional subclavian vein technique for CIED lead placement.

TRIAL REGISTRATION

www.clinicaltrials.gov, NCT02358551; https://clinicaltrials.gov/ct2/show/NCT02358551?term=NCT02358551& rank=1.

Association of Uninterrupted Oral Anticoagulation During Cardiac Device Implantation with Pocket Hematoma

PURPOSE

Implantation of permanent pacemakers (PPMs) or implantable cardiac defibrillators (ICDs) may be complicated by the development of pocket hematomas. Current practice guidelines provide little guidance to clinicians about the preferred strategy for chronic oral anticoagulation (OAC). The purpose of this study was to examine the frequency and clinical significance of pocket hematoma among patients receiving uninterrupted OAC during cardiac device implantation.

METHODS

This was a retrospective cohort study of adult patients undergoing cardiac device implantation between January 1, 2011, and December 31, 2012, at an academic teaching hospital. Medical records were reviewed for demographics, comorbidities, and medications. The primary outcome was development of pocket hematomas within 30 days of device implantation. Clinical significance was based on the need for additional intervention. Data were assessed using descriptive statistics, logistic regression, and chi-square tests.

RESULTS

The final cohort included 380 patients. The median age was 68.4 years, and 56.6% were male. Cardiovascular comorbidities were common. Among 80 patients receiving uninterrupted OAC, 71.3% were taking warfarin, 11.2% rivaroxaban, and 17.5% dabigatran. The incidence of pocket hematomas for the entire cohort was 9.7%, of which 1.3% were clinically significant. Pocket hematoma occurred in 21.4% of patients continued on OAC versus 7.7% of those not anticoagulated (P = .001). Pocket hematoma was more common among those receiving ICDs than PPMs (18.5% vs 5.7%, respectively; P < .001).

CONCLUSIONS

Continuing chronic OAC increased pocket hematoma formation but most were clinically insignificant. Pocket hematoma occurred irrespective of the oral anticoagulant drug used, but additional study is needed to determine comparative risks among the drugs.

Complications Related to Cardiac Rhythm Management Device Therapy and Their Financial Implication: A Prospective Single-Center TwoYear Survey

INTRODUCTION

Cardiac rhythm management devices (CRMDs) have proven their clinical effectiveness for patients with heart rhythm disorders. Little is known about safety and complication rates during the implantation of these devices. This study demonstrated the complication rates related to CRMD implantation, and estimated the additional hospital stay and cost associated with the management of complications.

METHODS

During a period of one year, a total of 464 consecutive recipients underwent CRMD implantation and were followed for 2 years. Finally, data were analyzed for 398 patients who completed the two-year follow up, resulting in a total of 796 patient-years.

RESULTS

Of the 201 patients with initial pacemaker (PM) implantations, 6 (2.99%) had seven complications (5 patients had lead dislodgement, 1 of them twice), and 1 patient developed pocket infection. Of the 117 PM replacements, 1 (0.85%) patient developed a complication (pocket erosion). Two patients with complications (1 with an initial PM and 1 with a replacement) died before completing the follow up for reasons unrelated to cardiac causes. There were no complications in either initial implantations (69 patients) or replacements (11 patients) of implantable cardioverter-defibrillators. The average prolongation of the hospital stay was 7 days, ranging from 1 to 35 days, resulting in 17,411 of total additional direct hospital costs.

CONCLUSION

This study found relatively low rates of complications in patients undergoing CRMD implantation, initial or replacement, in our center, compared with other studies. The additional hospitalization days and costs attributable to these complications depend on the nature of the complication.

Management of Cardiac Electronic Device Infections: Challenges and Outcomes

Cardiac implantable electronic device (CIED) infection is an increasing problem. Reasons for this are uncertain, but likely relate to an increasing proportion of implantable cardioverter defibrillator (ICD) and cardiac resynchronisation therapy (CRT) devices implanted, as well as implantations in 'higher risk' candidates, i.e. patients with heart failure, diabetes and renal failure. Challenges within the field of CIED infections are multiple with prevention being the most important challenge. Careful prescription of CIED treatment and careful patient preparation before implantation is important. Diagnosis is often difficult and delayed by subtle signs of infection. Treatment of CIED infection includes complete system removal in centres experienced in CIED extraction and prolonged antibiotic therapy. Meticulous planning and preparation before system extraction and later CIED re-implantation is essential for better patient outcome. Future strategies for reducing CIED infection should be tested in sufficiently powered, multicentre, randomised controlled trials.

An Unconventional Route of Left Ventricular Pacing

We present a case of a rare complication of transvenous right ventricular pacing by temporary pacing wire causing iatrogenic interventricular septal perforation and left ventricular pacing in a 69-year-old man who was referred for recurrent syncope with sinus arrest.

Percutaneous Implantation of an Entirely Intracardiac Leadless Pacemaker

BACKGROUND

Cardiac pacemakers are limited by device-related complications, notably infection and problems related to pacemaker leads. We studied a miniaturized, fully self-contained leadless pacemaker that is nonsurgically implanted in the right ventricle with the use of a catheter.

METHODS

In this multicenter study, we implanted an active-fixation leadless cardiac pacemaker in patients who required permanent single-chamber ventricular pacing. The primary efficacy end point was both an acceptable pacing threshold (≤2.0 V at 0.4 msec) and an acceptable sensing amplitude (R wave ≥5.0 mV, or a value equal to or greater than the value at implantation) through 6 months. The primary safety end point was freedom from device-related serious adverse events through 6 months. In this ongoing study, the prespecified analysis of the primary end points was performed on data from the first 300 patients who completed 6 months of follow-up (primary cohort). The rates of the efficacy end point and safety end point were compared with performance goals (based on historical data) of 85% and 86%, respectively. Additional outcomes were assessed in all 526 patients who were enrolled as of June 2015 (the total cohort).

RESULTS

The leadless pacemaker was successfully implanted in 504 of the 526 patients in the total cohort (95.8%). The intention-to-treat primary efficacy end point was met in 270 of the 300 patients in the primary cohort (90.0%; 95% confidence interval [CI], 86.0 to 93.2, P=0.007), and the primary safety end point was met in 280 of the 300 patients (93.3%; 95% CI, 89.9 to 95.9; P<0.001). At 6 months, device-related serious adverse events were observed in 6.7% of the patients; events included device dislodgement with percutaneous retrieval (in 1.7%), cardiac perforation (in 1.3%), and pacing-threshold elevation requiring percutaneous retrieval and device replacement (in 1.3%).

CONCLUSIONS

The leadless cardiac pacemaker met prespecified pacing and sensing requirements in the large majority of patients. Device-related serious adverse events occurred in approximately 1 in 15 patients. (Funded by St. Jude Medical; LEADLESS II ClinicalTrials.gov number, NCT02030418.).

Pacemaker insertion

A pacemaker (PM) (or artificial PM, so as not to be confused with the heart's natural PM) is a medical device that uses electrical impulses, delivered by electrodes contracting the heart muscles, to regulate the beating of the heart. The primary purpose of this device is to maintain an adequate heart rate, either because the heart's natural PM is not fast enough, or there is a block in the heart's electrical conduction system. Modern PMs are externally programmable and allow the cardiologist to select the optimum pacing modes for individual patients. Some combine a PM and defibrillator in a single implantable device. PMs can be temporary or permanent. Temporary PMs are used to treat short-term heart problems, such as a slow heartbeat that's caused by a heart attack, heart surgery, or an overdose of medicine. Permanent PMs are used to control long-term heart rhythm problems. A PM can relieve some arrhythmia symptoms, such as fatigue and fainting. A PM also can help a person who has abnormal HRs resume a more active lifestyle. In the current mini review we will focus on the insertion of a PM and the possible pneumothorax that can be caused.

Risk factors influencing complications of cardiac implantable electronic device implantation: infection, pneumothorax and heart perforation: a nationwide population-based cohort study

As the number of cardiac implantable electronic devices (CIEDs) is increasing annually, CIED-related complications are becoming increasingly important. The aim of the study was to assess the risks associated with CIEDs by a nationwide database. Patients were selected from the Taiwan National Health Insurance Database. Admissions for CIED implantation, replacement, and revision were evaluated and the evaluation period was 14 years. Endpoints included CIED-related infection, pneumothorax, and heart perforation. The study included 40,608 patients with a mean age of 71.8 ± 13.3 years. Regarding infection, the incidence rate was 2.45 per 1000 CIED-years. Male gender, younger age, device replacement, and previous infection were risks for infection while old age and high-volume centers (>200 per year) were protectors. The incidence of pneumothorax was 0.6%, with an increased risk in individuals who had chronic obstructive lung disease (COPD) and cardiac resynchronized therapy (CRT). The incidence of heart perforation was 0.09%, with an increased risk in individuals who had pre-operation temporal pacing and steroid use. High-volume center was found to decrease infection rate while male gender, young people, and individuals who underwent replacements were associated with an increased risk of infection. Additionally, pre-operation temporal pacing and steroid use should be avoided if possible. Furthermore, COPD patients or those who accept CRTs should be monitored closely.

Permanent leadless cardiac pacing: results of the LEADLESS trial

BACKGROUND

Conventional cardiac pacemakers are associated with several potential short- and long-term complications related to either the transvenous lead or subcutaneous pulse generator. We tested the safety and clinical performance of a novel, completely self-contained leadless cardiac pacemaker.

METHODS AND RESULTS

The primary safety end point was freedom from complications at 90 days. Secondary performance end points included implant success rate, implant time, and measures of device performance (pacing/sensing thresholds and rate-responsive performance). The mean age of the patient cohort (n=33) was 77±8 years, and 67% of the patients were male (n=22/33). The most common indication for cardiac pacing was permanent atrial fibrillation with atrioventricular block (n=22, 67%). The implant success rate was 97% (n=32). Five patients (15%) required the use of >1 leadless cardiac pacemaker during the procedure. One patient developed right ventricular perforation and cardiac tamponade during the implant procedure, and eventually died as the result of a stroke. The overall complication-free rate was 94% (31/33). After 3 months of follow-up, the measures of pacing performance (sensing, impedance, and pacing threshold) either improved or were stable within the accepted range.

CONCLUSIONS

In a prospective nonrandomized study, a completely self-contained, single-chamber leadless cardiac pacemaker has shown to be safe and feasible. The absence of a transvenous lead and subcutaneous pulse generator could represent a paradigm shift in cardiac pacing.

CLINICAL TRIAL REGISTRATION URL

http://clinicaltrials.gov. Unique identifier: NCT01700244.