Intermuscular abdominal implantation of permanent pacemakers in infants and children

Abdominal cardiac devices in pediatric and congenital heart disease: a practice model transition

BACKGROUND

Abdominal cardiac implantable electronic device maintenance procedures are traditionally performed by cardiac surgeons. The University of Michigan Congenital Heart Center transitioned from this practice model to one in which electrophysiologists perform the majority of these procedures. This study presents the outcomes of these procedures during this transition.

METHODS

Retrospective cohort study of all patients undergoing abdominal device maintenance procedure, inclusive of generator change, removal, or placement with preexisting leads from January 2005 to July 2013. Procedures involving epicardial lead placement were excluded. The primary outcome was major complications defined as any intraoperative complication, the requirement of an additional operative intervention, or hospitalization for device-related infection.

RESULTS

There were 113 procedures on 93 patients. Of these, 84 (74%) procedures were on patients with congenital heart disease. Cardiac surgeons performed 54 (48%) procedures and electrophysiologists performed 59 (52%). Mean age was 16 ± 11 years. The groups were similar regarding age and proportion with congenital heart disease (CHD). Major complications occurred in 3 (5.5%) cardiac surgeon procedures and 2 (3.4%) electrophysiologist procedures. There is no difference in the risk of major complications between groups (P = .59).

CONCLUSION

This 8.5-year period encompassed a practice model transition from cardiac surgeon-performed abdominal device procedures to primarily electrophysiologist-performed abdominal device procedures. There was no difference in the risk of complications between services. This suggests that electrophysiologist-performed abdominal cardiac device maintenance procedures are a viable practice model, provided there is support and collaboration from the cardiac surgery service.

Single midline approach for permanent pacemaker implantation in children

Permanent pacemaker implantation was carried out in 12 children with a mean age of 1.4 years (range, 2 days to 4 years) and a mean weight of 8.6 kg (range, 2.4-13.6 kg), using a single midline approach for placement of both the epicardial lead and the pacemaker generator (intermuscular abdominal implantation). Platinized porous-tipped steroid-eluting epicardial leads were used in all patients. The pacemakers worked well, and there was no early postoperative complication. This technique was found to be rapid, simple, and safe in children, especially neonates and infants.

Placement of a permanent epicardial pacemaker in children using a subcostal approach

BACKGROUND

Previously described techniques for epicardial pacemakers in children have generally included either a left thoracotomy approach or a subxiphoid incision.

METHODS

We have recently used a single left subcostal incision for placement of both the epicardial electrodes and the pacemaker generator. We report our initial experience with this technique in 8 patients. The mean age was 4 years (range, 4 months to 12 years). The smallest patient weighed 4,100 g.

RESULTS

The subcostal approach was successful in 7 patients. One patient with a narrow costal margin operated on early in our experience required conversion to a thoracotomy. The pacing thresholds were uniformly excellent in all patients. There have been no associated complications.

CONCLUSIONS

Placement of epicardial leads using a left subcostal incision avoids a thoracotomy, is simpler than a subxiphoid approach, and results in acceptable thresholds with minimal morbidity.

Permanent pacemaker implantation in premature infants less than 2,000 grams of body weight

Pacemaker implantation in premature infants presents technical problems because of the relatively larger size of the pulse generator compared with their bodies. A new technique with which successful generator implantation was performed in 2 premature infants less than 2,000 g of body weight is described. The generator is wrapped in a Gore-Tex surgical membrane. A piece of membrane overlying the electrical contact surface of the generator is removed, and the generator is fixed to the abdominal wall in the peritoneal cavity. The technique is simple to perform and would give relative ease in generator exchange.

A new technique for permanent pacemaker implantation in infants and children

Permanent pacemaker implantation in the infant or young child presents the surgeon with many technical problems unique to this population. A new technique of implantation is described that was used successfully in 6 pediatric patients. The technique is simple to perform and gives very satisfactory results.

Ventricular pacing in children

Ventricular pacing was performed in forty-one children ranging from one day to twenty years of age (median age = 10). Weight of the recipient at implant ranged from 2 kg. to 86 kg. Indications included presyncope, syncope, dyspnea on exertion, congestive heart failure, postoperative infra-Hisian heart block, and inadequate cardiac rate during pharmacotherapy. Four patients died during follow-up, but no deaths were attributable to pacemaker management. In contrast, 66% of the patients required more than one pacemaker related-operative procedure, and 43% of leads implanted failed by 48 hours. Indications for permanent cardiac pacing in this population at this time are symptomatic congenital AV block, symptomatic sinus node disease, and AV block in the postoperative period. Technological developments which might reduce complications seen in this population and electrophysiologic techniques which may better define indications for pacing in children are also reviewed.

Pacemaker implantation in infants and children: a simplified approach

A technique for epicardial pacemaker implantation is described. A single incision is utilized through which the electrode and power pack are implanted. Twelve infants and children were operated on in the last four years using this procedure. The marked improvement in cosmetic appearance and the relative ease in module replacement are major advantages of this method.