Pediatric Pacemaker Implantation Endocardial or Epicardial

Transcription

1 Pediatric Pacemaker Implantation Endocardial or Epicardial HAITHAM BADRAN, MD, FEHRA CONSULTANT OF INTERVENTIONAL CARDIOLOGY CONSULTANT OF CARDIAC PACING AND ELECTROPHYSIOLOGY LECTURER OF CARDIOLOGY AIN SHAMS UNIVERSITY

2 Background Pacemaker therapy in children involves unique issues regarding patient size growth and development possible presence of congenital heart disease

3 The worldwide incidence of congenital heart disease among full-term infants has averaged 0.4% to 0.9% Approximately open-heart operations are performed annually in the US on patients with CHD, and >85% of infants can now be expected to reach adulthood.

4 The favorable results of cardiac palliative & corrective surgeries in neonates, infants, and children Surgically acquired conduction disturbances Based on these facts, PPMs have a growing use in pediatric population due to congenital and surgically acquired rhythm disturbances

5 Rhythm disturbances in CHD Most common 1-3% (AV canal repair).walsh E & Cecchin F Circulation, 2007 Harvard medical School

6 ACC/AHA/HRS

7 Technical Considerations Congenital (or acquired) structural heart disease presents additional issues for pacemaker implantation in children. Transvenous vs Epicardial. Single or dual chamber.

8 Before choosing the type of PPM,there are unique technical & clinical issues that must be considered with the implantation of devices in small patients and those with CHD. So, careful pre-procedural planning is essential for successful pacemaker implantation in children

9 Patient size Despite recent miniaturization of pulse generators & leads: Average PPM generator size 8-12 Cm 3 VVI battery DDD battery size precludes transvenous implantation in smaller pts

10 Reports of several centers suggested a B. wt of Kg or Kg as a lower range for consideration of uncomplicated trans-venous VVI implants & > Kg for DDD (Silvetti et al, Europace 2006) Sachweh et al, pts (children & adolescents) with PPM implantation :

11 Only 1 center experience with implanting devices in neonates & infants reported successful transvenous implants at average of 4.9 Kg Silvetti et al Europace pts (neonates & infants < 1yr ): That was at early experience of the institute institute preference shifted to epicardial implants

12 Transvenous pacing Ain Shams University Hospital Venous access Subclavian vein Cephalic vein Lead type Passive fixation Active fixation VVIR PM in symptomatic CCHB HR 45 bpm,11 yrs old child, 34 kg 134 cm Medtronic SIGMA SSR Pacing modes VVIR AAIR VDD DDD/R

13 Challenges in Transvenous pacing Transvenous route is a reasonable approach for children weighing at least kg, although successful transvenous pacing is reported in neonates without complications. Physical considerations that may preclude transvenous pacing include intracardiac shunting, low-flow states, and anatomic barriers (eg, mechanical tricuspid valves).

14 Transvenous lead placement in congenital heart patients often requires nonstandard positioning because of variations in venous and intracardiac anatomy. The atrial appendage is sometimes amputated with cannulation for cardiac bypass, and atrial anatomy is often different. The use of active-fixation leads allows easier sampling of nonstandard pacing sites and easier removal

15 In specific operations for congenital heart disease, such as the Fontan procedure, the right medial wall often is viable in postoperative Mustard and Senning procedures, superior aspects of the systemic venous atrium are optimal. High-output pacing is imperative testing for diaphragmatic or phrenic nerve stimulation, particularly in lateral pacing sites. The active pacing lead tip may be used for mapping of optimal tissue implant sites.

16 Advantages of the transvenous route I Avoidance of thoracotomy, lower pacing thresholds (and thus longer battery life) lower incidences of exit block and lead fractures. Disadvantages Slightly higher dislodgment rate (eg, with passive fixation devices) Potential venous occlusion possible embolic events (eg, from an intracardiac shunt) Slight risk of endocarditis, and subclavian crush syndrome. Twiddler syndrome can also occur in children with potential lead dislodgment, generator migration, or pacing failure due to twisting of leads or generator in the pocket. Significant vascular access challenges can also relate to congenital heart diseases and surgical corrections.

17 Epicardial Pacing Surgical approach Sternotomy Lateral thoracotomy Sub-xyphoid approach Thoracoscopy or robotic Battery insertion Rectus sheath Lateral abdominal wall Epicardial DDD PM in a child with complex CHD

18 EPICARDIAL Epicardial pacing is primarily used when transvenous pacing is contraindicated or for patients undergoing concomitant heart surgery. Contraindications to transvenous pacing include: prosthetic tricuspid valves right-to-left intracardiac shunts congenital heart disease or surgery precluding transvenous access to cardiac chambers, recurrent transvenous lead dislodgment, and, probably, minimum patient size.

19 Advantages of Epicardial implantation Absence of a need to provide vascular continuity with cardiac chambers and the avoidance of concerns about venous thrombosis. Disadvantages More frequent reports of sensing and capture failure, higher rates of insulation and conductor fractures, and the need for an open chest approach (eg, via a thoracotomy, a sternotomy, or a subxiphoid or subcostal incision).

20 Long-term efficacy & survival Silvetti et al, Europace 2006 : 20 yrs experience in pediatric pacing: 515 PM in 292 pts High failure rate in epicardial leads High pacing threshold Exit block Frequent trauma Lead fracture due to somatic growth

21 Silvetti et al, Europace yrs experience in pediatric pacing: 515 PM in 292 pt year conventional epicardial lead survival : 40% - 70%. 5-year epicardial (streoid eluting) lead survival 83% which compares reasonably well with reported conventional endocardial systems ( Cohen et al, 2001)

22 Pacing Threshold Battery longevity Several reports, showed lack of statistically significant difference in sensing thresholds & impedance.

23 Technical Challenges Knowledge of the anatomy Congenital venous anomalies lack of venous access to heart Acquired venous occlusion Surgical obstacles (patches, conduits & baffles) Single ventricle physiology (Fontan) Unusual ventricular geometry (Senning & Mustard repair of TGA) Intracardiac shunts (PFO, patch leaks) Epicardial PPM

24 Future growth 6 yrs, 20 Kg, 123cm, post op CHB, TOF repair Jan Sept. 2008

25 Ain Shams University 8 yrs old, post VSD closure CHB

26 Acute & Late complications Most centers reported lack of sign. difference between epicardial and Tranvenous Khairy et al (Circulation. 2006;113: )

27 Ain Shams University Hospital 12 yrs old, CCAVB, VVIR, traumatic skin erosion Medtronic SIGMA SSR 203

28 Ain shams Unviersity Hospital Overstretch of the lead by somatic growth physical hyperactivity

29 Finally. As a general rule : less leads implanted simplest pacing system Small children better to start with Epicardial

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31 QUESTIONS?