Experience with an implantable synchronous pacemaker in children

Pacemakers in children: an update

This report reviews recent pacemaker technological advances as they apply to infants, children, and adolescents. Indications for pacemaker implantation in children have evolved since the 1984 Joint Task Force Guidelines. Recent data show that pacemaker implantation should be strongly considered in patients who have (1) asymptomatic congenital complete AV block with a mean heart rate less than 50 beats/min or other evidence of junctional instability; (2) congenital AV block with long QT interval; or (3) congenital long QT syndrome with bradyarrhythmias, or when conventional beta-blocker therapy is unsuccessful. Permanent pacemaker implantation is not necessarily an effective prophylactic measure against sudden death in patients following their operation who are receiving drug therapy for atrial tachyarrhythmias, and so is not absolutely indicated. New developments in lead technology have made transvenous lead systems more feasible for pediatric use. Because epicardial leads are required for small infants and for cosmetic reasons in some older children, design improvements are needed to enhance epicardial lead performance. Rate-responsive pacing is an acceptable alternative to dual-chamber pacing for augmenting exercise tolerance, and for children with sinus node dysfunction it is the preferred pacing mode. Pacemakers with automatic antitachycardia capabilities and with noninvasive electrophysiology features are valuable in children with atrial tachyarrhythmias. New data suggest that chronic atrial pacing also may be effective in controlling atrial tachyarrhythmias. New developments in pacemaker systems for the young parallel those for the older population, but differences between adult and pediatric patients demand ongoing increased participation by pediatric cardiologists.

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.

Electrophysiologic residua and sequelae of surgery for congenital heart defects

Postoperative arrhythmias may occur in any patient who undergoes intracardiac surgery for a congenital heart defect. The correction of certain intracardiac heart defects predisposes to a large incidence of cardiac arrhythmias. Ventricular arrhythmias and conduction disturbances are seen after correction of tetralogy of Fallot, ventricular septal defect and atrioventricular canal defect. Supraventricular arrhythmias and sinus nodal dysfunction may be seen after surgery for transposition of the great arteries or atrial septal defect. The identification, evaluation and treatment of these patients are discussed.

Intrapleural permanent pacemakers in infancy

The pleural cavity offers a suitable site for permanent pacemaker implantation in infancy. We describe 3 infants in whom this approach was successfully used.

Manual extraction of a permanent pacemaker: an attempted suicide

An unusual case of a patient-related pacemaker malfunction is presented. In a suicide attempt the patient manually extracted a subcutaneously implanted permanent pacemaker. This shocking example of pacemaker manipulation by a patient raises the question of the need for more routine of protected sites for pacemaker implantation.

The recessed chest wall pacemaker pocket

Recurrent pouch problems led to the development of a recessed chest wall pacemaker pocket. Segments of the seventh and eighth ribs were resected in the mid-axillary line resulting in a "tailor-made" space suitable for generator implantation. Follow-up at one year has proven the chest wall to be a satisfactory alternative site for a pacemaker pocket.

Intermuscular abdominal implantation of permanent pacemakers in infants and children

Pacemaker implantation in infants and young children presents technical problems because of the relatively large size of the units. Various implantation sites have been employed to avoid the problems of unsightliness, migration, skin necrosis with infection, and patient discomfort. We are presenting a new technique which obviates these difficulties. The pacemaker generator is located in a space developed between the muscles and fascia of the abdominal wall. This site will accept even the largest of demand pacemakers with cosmetically acceptable results.

Fourteen years of implanted pacemakers in children

Twenty-six children who had permanent pacemakers implanted at 6 hours to 11 years of age have been followed for up to 163 months. There were 14 children with surgical heart block, 9 with congenital heart block, 2 with postcatheterization complete heart block, and 1 with bradytachydysrhythmia syndrome. Eighteen of the 26 patients (69%) are still being paced with their original electrodes, some for more than eight years. Sixty pulse generators lasted an average of 17 months (range, 1 to 55 months). Five of the 26 patients (19%) are dead. Three died of noncorrectable heart disease, but there were 2 sudden unexplained deaths at home, both apparently due to sudden arrhtthmias. Both of these patients had received fixed-rate pulse generators, and 1 had a known potential for competing rhythms. The current optimal choices of equipment and techniques, including the role of synchronized, demand, lithium-powered, and nuclear-powered pulse generators, are discussed.

Cardiac pacing in children and adolescents

Nineteen patients aged 1 month to 18 years underwent implantation of a cardiac pacemaker and were followed up for up to 9 years (average duration of pacing 54 months). Complete heart block was present in 16 patients and sinus nodal dysfunction in 3. Heart block was presumably of congenital orgin in eight, secendary to cardiac surgery in seven and subsequent to cardiac catheterization in one. Sinus nodal dysfunction was of presumed congenital origin in one and occurred after cardiac surgery in two. Pacing was required because of syncopal attacks in eight patients, three of whom had congestive heart failure or low cardiac output on physiologic studies. It was required in four because of congestive heart failure, in two because of low cardiac output (one with a wide QRS complex), and in five for postoperative rhythm control. With return of sinus rhythm after 2 and 3 months, respectively, pacing was discontinued in two patients. One child was partially corrected disease died within 3 months, one died of wound breakdown and sepsis after 10 months of pacing and one died suddenly 4 years after implantation. All others have returned to normal activity; only one requires cardiac medication. The degree of emotional stability has been striking. Asynchronous and atrial synchronous pacing are of equal therapeutic value. The very small radiofrequency implanted receiver has been useful in younger children. The major problems have been caused by the large size and short longevity of the generators and the child's growth stressing the lead system. Transvenously implanted pacemakers have presented no greater management problems than those placed during thoracotomy.