Clinical analysis of temporary pacemaker implantation in 6 children with fulminant myocarditis

BACKGROUND

There is little literature on the use of temporary pacemakers in children with fulminant myocarditis. Therefore, we summarized the use of temporary cardiac pacemakers in children with fulminant myocarditis in our hospital.

METHODS

The clinical data of children with fulminant myocarditis treated with temporary pacemakers in Wuhan Children's Hospital from January 2017 to May 2022 were retrospectively analyzed.

RESULTS

A total of 6 children were enrolled in the study, including 4 boys and 2 girls, with a median age of 50 months and a median weight of 15 kg. The average time from admission to pacemaker placement was 2.75 ± 0.4 h. The electrocardiogram showed that all 6 children had third-degree atrioventricular block (III°AVB). The initial pacing voltage, the sensory sensitivity of the ventricle and the pacing frequency were set to 5-10 mV, 5 V and 100-120 bpm respectively. The sinus rhythm was recovered in 5 patients within 61 h (17-134) h, and the median time of using temporary pacemaker was 132 h (63-445) h. One of the children had persistent III°AVB after the temporary pacemaker. With parental consent, the child was fitted with a permanent pacemaker on the 12th day of his illness.

CONCLUSIONS

When fulminant myocarditis leads to severe bradycardia or atrioventricular block in children, temporary pacemakers have the characteristics of high safety to improve the heart function.

Atrioventricular conduction disorders in aortic valve infective endocarditis

BACKGROUND

Aortic valve infective endocarditis may be complicated by high-degree atrioventricular block in up to 10-20% of cases.

AIM

To assess high-degree atrioventricular block occurrence, contributing factors, prognosis and evolution in patients referred for aortic infective endocarditis.

METHODS

Two hundred and five patients referred for aortic valve infective endocarditis between January 2018 and March 2021 were included in this study. A comprehensive assessment of clinical, electrocardiographic, biological, microbiological and imaging data was conducted, with a follow-up carried out over 1 year.

RESULTS

High-degree atrioventricular block occurred in 22 (11%) patients. In univariate analysis, high-degree atrioventricular block was associated with first-degree heart block at admission (odds ratio 3.1; P=0.015), periannular complication on echocardiography (odds ratio 6.9; P<0.001) and severe biological inflammatory syndrome, notably C-reactive protein (127 vs 90mg/L; P=0.011). In-hospital mortality (12.7%) was higher in patients with high-degree atrioventricular block (odds ratio 4.0; P=0.011) in univariate analysis. Of the 16 patients implanted with a permanent pacemaker for high-degree atrioventricular block and interrogated, only four (25%) were dependent on the pacing function at 1-year follow-up.

CONCLUSIONS

High-degree atrioventricular block is associated with high inflammation markers and periannular complications, especially if first-degree heart block is identified at admission. High-degree atrioventricular block is a marker of infectious severity, and tends to raise the in-hospital mortality rate. Systematic assessment of patients admitted for infective endocarditis suspicion, considering these contributing factors, could indicate intensive care unit monitoring or even temporary pacemaker implantation in those at highest risk.

Rate of various access sites for temporary transvenous pacing and different outcomes at Lady Reading Hospital, Peshawar Pakistan

Objective

To evaluate the various temporary transvenous pacemaker (TPM) access sites, its indications, procedural complications, and outcomes of patients.

Methods

This prospective study conducted in a tertiary care hospital of Peshawar, included 100 patients, who underwent TPM for any reasons, via the trans jugular, subclavian, or trans-femoral route. The duration of the study was from October 1st, 2021 to March 31st, 2022. The demographic, procedure -related complications, causes of complete heart block and in hospital outcomes were recorded.

Results

Of the 100 patients who underwent temporary transvenous pacing, 56%were males and 44% were females, with an age range of 46-80 years. In majority of the patients, (N =54) internal jugular vein was used as the venous access site followed by the subclavian vein. (N=24). Coronary artery disease was prevalent in 42% of the patients. 50% had complete AV block, 19% had symptomatic second-degree block, and 10% had sinus nodal diseases. Seventy three percent of the patients needed TPM implantation on an emergency basis, which is statistically significant (p=0.009). Almost 40% of the patient ultimately underwent a permanent pacemaker. Out of 100 patients, 16 patients expired. The major procedure related complications were bleeding 16% overall at the puncture site and 14.8% in the internal jugular group. Other complications were local infection 13% at the insertion site followed by hemopericardium 3%, in the internal jugular group.

Conclusion

Atrioventricular block is the commonest indication for temporary pacing in our study. The average time the TPM remained in place was significantly higher in the trans jugular approach group along with a higher complication rate in this group.

Conduction Disturbance, Pacemaker Rates, and Hospital Length of Stay Following Transcatheter Aortic Valve Implantation with the Sapien 3 Valve

Background

In the absence of randomized data, an expert panel recently proposed an algorithm for conduction disturbance management in transcatheter aortic valve implantation (TAVI) recipients. However, external validations of its recommendations are limited.

Methods

We retrospectively identified 808 patients without a pre-existing pacing device who underwent transfemoral TAVI with the Sapien 3 valve at our institution in 2018-2019. Patients were grouped based on pre-existing conduction disturbance and immediate post-TAVI electrocardiogram. Timing of temporary pacemaker (TPM) removal and hospital discharge were compared with those of the expert panel recommendations to evaluate the associated risk of TPM reinsertion and permanent pacemaker (PPM) implantation.

Results

In most group 1 patients (no electrocardiogram changes without pre-existing right bundle branch block), the timing of TPM removal and discharge were concordant with those of the expert panel recommendations, with low TPM reinsertion (0.8%) and postdischarge PPM (0.8%) rates. In the majority of group 5 patients (procedural high-degree/complete atrioventricular block), TPM was maintained, followed by PPM implantation, compatible with the expert panel recommendations. In contrast, in groups 2-4 (pre-existing/new conduction disturbances), earlier TPM removal than recommended by the expert panel (mostly, immediately after procedure) was feasible in 97.5%-100% of patients, with a low TPM reinsertion rate (0.0%-1.8%); earlier discharge was also feasible in 50.0%-65.5%, with a low 30-day postdischarge PPM rate (0.0%-2.8%) and no 30-day death.

Conclusions

Early TPM removal and discharge after TAVI appear safe and feasible in the majority of cases. These data may provide a framework for an early, streamlined hospital discharge plan for TAVI recipients, optimizing both cost savings and patient safety.

Clinical analysis of temporary pacemaker implantation in 13 children

BACKGROUND

At present, temporary pacemaker implantation is very common in the treatment of cardiovascular diseases in adults. However, the number of pediatric pacemakers implanted is still relatively small, and relevant research is also far less than that of adults. This study aimed to explore the application of temporary pacemakers in children with acute and critical cardiovascular diseases.

METHODS

The clinical data of children with cardiovascular diseases who were treated with temporary pacemakers in Tianjin Children's Hospital from October 2017 to February 2021 were analyzed retrospectively.

RESULTS

A total of 13 children with cardiovascular diseases were included in this study, including 4 males and 9 females, mean age of 71.2±56.3 months, and median body weight of 15.5 kg. There were 9 children with endocardial pacing and 4 children with epicardial pacing. The types of diseases included fulminant myocarditis (n=8), complete atrioventricular block (CAVB; n=1), and arrhythmias after open heart surgery (n=4). The median time from onset to admission was 1.0 days in children with endocardial pacing and there was cardiac arrest in 2 children, heart failure in 9 children, cardiogenic shock in 8 children, and Adams-Stokes attack in 7 children. The median time from admission to implantation of temporary pacemakers was 3.0 h and the operation time was 55.0±19.4 min. All 4 children with epicardial pacing had pacemakers implanted during operation because of CAVB. The pacing mode was VVI mode. The initial perceptual voltage was 1-2 mv, the output voltage was 5v, and the pacing frequency was 70-145 bpm. A total of 11 children reverted to sinus rhythm within 5.0 (1.8-34.0) h and the working time of temporary pacemakers was 134.0 (15.0-191.0) h. There was poor pacing in 2 children and catheter displacement in 1 child during pacing. A total of 12 children were followed up for 20.0±12.5 months and 1 was lost to follow-up. During the follow-up period, the cardiac functions were basically normal and no new arrhythmia appeared.

CONCLUSIONS

Temporary pacemakers have the advantage of simple operation, definite effect, and safety which has a remarkable effect in the treatment of acute and critical cardiovascular diseases in children.

Bedside Temporary Transvenous Pacemaker Insertion in the Emergency Department: A Single-Center Experience

Objectives

Insertion of a temporary transvenous pacemaker (TTPM) is one of the life-saving interventions performed in the emergency department (ED). The aim of the study was to determine demographic, clinical characteristics, and in-hospital outcomes of patients who underwent TTPM insertion due to hemodynamically unstable bradyarrhythmia in the ED.

Methods

In our study, 234 consecutive patients who underwent TTPM insertion at the bedside in the ED between January 2014 and October 2019 were included in the study. Etiological characteristics, electrocardiographic (ECG) findings, requirements for permanent pacemaker (PPM), and in-hospital mortality of the patients were analyzed retrospectively.

Results

Extrinsic causes were the most common etiology of unstable bradyarrhythmia (57.6%). Most extrinsic causes were drug therapy-related factors (60.7%). Bradyarrhythmia persisted in 60% of patients after extrinsic causes were eliminated. The most common ECG finding was a high-degree atrioventricular block (62%). PPM was implanted in 44% of patients. In-hospital mortality rate was 19.7%. In the multivariate regression analysis, the left ventricular ejection fraction (LVEF) and diastolic blood pressure (DBP) measured at admission (p<0.001 and p<0.001, respectively) were determined to be independent predictors for in-hospital mortality.

Conclusion

First diagnosis and intervention in the ED are of great importance for patients with unstable bradyarrhythmia. The fastest possible TTPM insertion in the ED can reduce mortality by reducing the exposure time to hypoperfusion of vital organs, especially in patients with reduced LVEF and low DBP. Furthermore, it should be kept in mind that an underlying latent conduction system disease can also be present in bradyarrhythmias thought to occur potentially due to extrinsic factors.

Temporary pacemaker protected transjugular intrahepatic portosystemic shunt in a patient with acute variceal bleeding and bradyarrhythmia: A case report

BACKGROUND

Esophagogastric varices are a common complication of cirrhosis with portal hypertension and endoscopic treatment has been recognized as a primary preventive and therapeutic option for such patients; however, it should be noted that bradyarrhythmia is regarded as one of the contraindications to endoscopic examination. Meanwhile, acute variceal bleeding may result in a high mortality rate in cirrhotic patients with portal hypertension accompanied by bradyarrhythmia. At present, there is an absence of reports concerning the treatment of such group of patients who underwent transjugular intrahepatic portosystemic shunt (TIPS). The present report details the case of a cirrhotic patient with acute variceal bleeding accompanied by bradyarrhythmia who underwent TIPS under temporary pacemaker protection.

CASE SUMMARY

We report the case of a 64-year-old male patient who was confirmed with bradyarrhythmia by ambulatory electrocardiogram 24 h before the operation. The patient was successfully treated by TIPS under temporary pacemaker protection.

CONCLUSION

In terms of cirrhotic patients with abnormal cardiac electrophysiological conduction, TIPS may be effective in reducing the complications of portal hypertension following the exclusion of severe pulmonary hypertension and heart failure, showing moderate feasibility in clinical applications.

Temporary pacemaker insertion for severe bradycardia following pneumoperitoneum during robot-assisted radical prostatectomy: a case report

Background

Pneumoperitoneum to maintain a constant gas flow to assist various surgeries is known to cause severe bradycardia and has been linked to heart failure;; however, a recent study demonstrated that it is not linked to poorer surgical outcomes; accordingly, it does not require routine preventive measures. Thus, whether there is a link between sudden bradycardia development and surgical procedures is controversial. We report the case of severe bradycardia that occurred along with a complete atrioventricular block (CAVB) during peritoneum creation in robot-assisted radical prostatectomy (RARP).

Case presentation

A 72-year-old man presented at our hospital with prostate cancer and underwent RARP. After pneumoperitoneum, severe bradycardia and CAVB were observed; thus, the surgery was extended by inserting a temporary pacemaker (TPM).

Conclusion

Because of the difficulty in performing emergency procedures in robot-assisted surgeries, the current case is reported to provide an awareness that surgeons should be cautious of the possible complication of bradycardia and CAVB during such operations, and thus should take steps necessary for managing induction of such conditions.

A novel technique to avoid perforation of the right ventricle by the temporary pacing lead during transcatheter aortic valve implantation

Cardiac tamponade is a life-threatening complication during transcatheter aortic valve implantation (TAVI), often caused by perforation of the right ventricle (RV) by the temporary pacemaker used for rapid pacing during valve deployment. We aimed to assess the feasibility of performing rapid pacing while maintaining inflation of the pacing lead balloon in the RV during TAVI. Among 749 consecutive patients who underwent TAVI with SAPIEN XT valves between October 2013 and July 2015, 726 treated using rapid pacing with a transvenous balloon-tip lead were enrolled in our study, and were stratified into three groups according to the extent of balloon inflation in the RV as follows: full inflation (n = 100), partial inflation (n = 196), and deflation (n = 430). We compared the following clinical outcomes: pacing lead-related RV perforation, rapid pacing failure, valve malpositioning due to rapid pacing failure, device success, and 30-day mortality. Pacing lead-related RV perforation occurred only in patients in the deflation group (6 cases, 1.4%), but the differences among the groups were not statistically significant (p = 0.13). Rapid pacing failure, but no valve malpositioning, occurred most frequently in patients in the full inflation group (4.0% vs. 0.5% in the other groups, p = 0.004). The rate of device success (> 94%) and the 30-day mortality (2.0%) were similar among the three groups. Partial inflation of the balloon of the pacing lead may reduce the risk of RV perforation without increasing the risk of pacing failure or valve malpositioning.

Bedside temporary transvenous cardiac pacemaker placement

Temporary transvenous cardiac pacing is a life-saving procedure in an emergency. Transvenous cardiac pacing catheterization guided by intracavitary electrocardiogram (IC-ECG), instead of fluoroscope, is practical. Tips for controlling the orientation of the pacing catheter tip and utilizing IC-ECG to monitor the positions of electrodes make bedside temporary transvenous cardiac pacing catheter placement feasible and 'visible'. The technique discussed here is comparable to the operation under fluoroscopy，but without exposure to X-ray.

Cardiac magnetic resonance imaging in a patient with temporary external pacemaker: a case report

Background 

Magnetic resonance imaging (MRI) is increasingly becoming the imaging modality of choice for many clinical disorders due to superior image quality and absence of radiation. However, access to MRI remains limited for most patients with cardiac implantable electronic devices due to potential safety concerns. In line with guidelines, there is no absolute contraindication to perform MRI, but warrants careful risk-benefit assessment.

Case summary 

A 59-year-old man was admitted with a 5-day history of central chest pain and few week’s history of general malaise, dry cough, and breathlessness. Electrocardiogram confirmed complete atrioventricular block (CAVB). A slight increase in cardiac enzyme was noted. Coronary angiogram revealed atheromatous changes, but no obstructive coronary lesion. A temporary transvenous pacemaker was inserted. Transthoracic echocardiogram confirmed a dilated left ventricle with severely reduced left ventricular function. To facilitate diagnosis (hence prognosis), management and mobilization, investigation with cardiovascular magnetic resonance (CMR) was warranted but contraindicated by the temporary transvenous pacemaker. An active fixation pacemaker lead was therefore placed in the right ventricle via percutaneous puncture of the right subclavian vein and connected to a pulse generator, both secured to the skin with sutures and adhesive medical dressing. Appropriate device programming and close patient monitoring ensured that CMR could be performed without any adverse effects. A diagnosis of acute myocarditis was confirmed. Regular device interrogation during an extended 3-week period with temporary pacing ruled out any device failure. As there was no resolution of CAVB, the patient received a dual-chamber pacemaker.

Discussion 

Cardiovascular magnetic resonance was feasible and safely performed on a patient with a temporary permanent external pacemaker system using a standard screw-in pacing lead and a regular pulse generator fixed to the skin. Although more studies are needed for generalizability, CMR may be used in highly selected patients with a temporary pacemaker.

Feasibility and safety of exclusive echocardiography-guided intravenous temporary pacemaker implantation

BACKGROUND

The standard approach for urgent trans-venous temporary cardiac pacemaker (TVTP) implantation is fluoroscopy guidance. The delay in activation of the fluoroscopy-room and the transfer of unstable patients may be life-threatening. Echocardiography-guided TP implantation may increase the safety of the patients by obviating the need for in-hospital transfer. We examined the feasibility and safety of echocardiography-guided vs. fluoroscopy-guided TVTP implantation.

METHODS

From January 2015 to September 2017 data for consecutive patients who needed emergent TVTP implantation were retrospectively reviewed. Ultrasound-guided TVTP protocol that was introduced in our center in January 2015 involved ultrasound guidance for both central venous access and pacing lead positioning. Access sites included femoral, subclavian, or jugular veins. Electrodes were placed in the right ventricular apex by means of echocardiographic monitoring in intensive care unit or by fluoroscopic guidance. Endpoints were achievement of successful ventricular pacing and procedural complications.

RESULTS

Sixty-six patients (17 echocardiography-guided and 49 fluoroscopy-guided) were included. There were no differences in pacing threshold between the echocardiography-guided group and the fluoroscopy-guided group (0.75 ± 0.58 mA vs. 0.57 ± 0.35 mA, p = 0.24). The access site for implantation was femoral vein in 27% for the fluoroscopy-guided vs. none for the echocardiography-guided approach (p = 0.015). One hematoma and one related infection occurred in the fluoroscopy-guided group. The need for electrode repositioning was observed in 1 patient in each group. There were no procedural-related deaths in either group.

CONCLUSIONS

Echocardiography-guided temporary cardiac pacing is a feasible and safe alternative to fluoroscopy-guided approach and significantly lowers the need for in-hospital transfer.

Successful Restoration of Complete Heart Block to Normal Sinus Rhythm by Primary Angioplasty of Dual Left Anterior Descending Artery

Dual left anterior descending (LAD) artery is a rare coronary anomaly. We present a patient with a rare case of dual LAD, smaller one arising from the left main coronary stem and larger one from right coronary artery who presented with acute anterior wall myocardial infarction with complete heart block (CHB). Temporary pacemaker was implanted and coronary angiogram revealed critical occlusion of proximal LAD which was subsequently revascularized by primary angioplasty using drug-eluting stent (Xience prime, 2.75 × 23 mm) leading to recovery of CHB and restoration to normal rhythm. To the best of our knowledge, this is the first reported case of dual LAD presenting with CHB treated by primary angioplasty reported in the literature.

Giant unruptured sinus of Valsalva aneurysm with complete heart block

In this rare case report of giant unruptured sinus of Valsalva aneurysm (SOVA), a 17-year-old male presented with sudden onset syncope due to complete heart block (CHB). An emergency evaluation was done with the help of transthoracic echocardiography, transesophageal echocardiography, and cardiac catheterization with support of temporary pacemaker. The obvious distorting effects of a giant SOVA dissecting into interventricular septum were CHB, significant regurgitation of tricuspid and mitral valve, mild regurgitation aortic valve and biventricular dysfunction. The case was treated by repair of SOVA and posterior mitral ring annuloplasty. CHB improved to sinus rhythm on 11th day after surgery. On follow-up, tricuspid valve regurgitation improved to mild regurgitation and he continued to have mild aortic regurgitation. <Learning objective: Sinus of Valsalva aneurysm (SOVA) may present with cardiac emergency without rupture. A giant unruptured SOVA competes for space with neighboring intra cardiac structures. The distorting effects are erosion into interventricular septum, complete heart block (CHB), valvular and ventricular dysfunction. Transthoracic and transesophageal echocardiography provide enough information for emergency surgery. Sometimes, evaluation may need cardiac catheterization and computed tomography. Immediate surgery saves life. CHB may improve on follow-up.>.

Utility and safety of temporary pacing using active fixation leads and externalized re-usable permanent pacemakers after lead extraction

AIMS

After extraction of an infected cardiac implantable electronic device (CIED) in a pacemaker-dependent patient, a temporary pacemaker wire may be required for long periods during antibiotic treatment. Loss of capture and under sensing are commonly observed over time with temporary pacemaker wires, and patient mobility is restricted. The use of an externalized permanent active-fixation pacemaker lead connected to a permanent pacemaker generator for temporary pacing may be beneficial because of improved lead stability, and greater patient mobility and comfort. The aim of this study was to investigate the efficacy and safety of a temporary permanent pacemaker (TPPM) system in patients undergoing transvenous lead extraction due to CIED infection.

METHODS AND RESULTS

Of 47 patients who underwent lead extraction due to CIED infection over a 2-year period at our centre, 23 were pacemaker dependent and underwent TPPM implantation. A permanent pacemaker lead was implanted in the right ventricle via the internal jugular vein and connected to a TPPM generator, which was secured externally at the base of the neck. The TPPM was used for a mean of 19.4 ± 11.9 days (median 18 days, range 3-45 days), without loss of capture or sensing failure in any patient. Twelve of 23 patients were discharged home or to a nursing facility with the TPPM until completion of antibiotic treatment and re-implantation of a new permanent pacemaker.

CONCLUSION

External TPPMs are safe and effective in patients requiring long-term pacing after infected CIED removal.

Failure to Treat Torsades de Pointes

A healthy 22 year old male with no history of cardiac disease was admitted with severe community acquired pneumonia that was initially treated with moxifloxacin and azithromycin. At admission, he was found to be hypokalemic and hypomagnesemic. Two days after admission, he experienced several episodes of Torsades de Pointes (TdP). He was initially treated with isoproterenol. A temporary transvenous pacemaker was inserted and set at a rate of 100 bpm. After correction of electrolytes, withdrawal of QT-prolonging medications and ventricular pacing at the mentioned heart rate, another episode of TdP ensued.We report and discuss a case of recurrent TdP in spite of conventional acute management for this condition.