Patient, procedural, and hardware factors associated with pacemaker lead failures in pediatrics and congenital heart disease

doi:10.1016/j.hrthm.2004.02.020

Heart Rhythm

Volume 1, Issue 2, July 2004, Pages 150-159

https://doi.org/10.1016/j.hrthm.2004.02.020 Get rights and content

Abstract

Objectives

To examine outcomes of children with pacemakers over a 22-year period and identify risk factors for lead failure.

Background

Small patient size, structural cardiac abnormalities, and growth may complicate pediatric pacemaker management. Better knowledge of risk factors for lead failure in these patients may help improve future outcomes.

Methods

All pacemaker patients followed at one pediatric center 1980–2002 were included. Lead failures were identified retrospectively as leads repaired, replaced, or abandoned due to fracture, insulation break, dislodgement, or abnormalities in pacing or sensing. Risk factors were identified using logistic regression and Cox analyses.

Results

A total of 1007 leads were implanted in 497 patients during the study period (5175 lead-years). Median age at implant was 9 years (0–55); 64% of patients had structural congenital heart disease. Median follow-up time was 6.2 years (0–22). Lead failure occurred in 155 leads (15%), and 115 patients (23%), with 28% of patients experiencing multiple failures. Significant independent correlates of lead failure included age <12 years at implant, history of structural congenital heart defects, and epicardial lead placement. Younger patients (<12 years) experienced significantly more lead fractures than older children (P = .005), while patients with congenital heart defects experienced more exit block. Epicardial leads were more likely to fail due to fracture or exit block, while transvenous leads failed more due to insulation breaks or dislodgements.

Conclusions

Pediatric pacing patients have a high incidence lead failures. These occur most commonly in younger patients, structural congenital heart disease, and those with epicardial lead systems. Approaches to pacing system implantation and follow-up in these patients need to be individualized, with special attention to minimizing risk of lead failures. Our findings suggest that expanded utilization of transvenous systems in smaller patients seems justified when anatomy permits.

Section snippets

Design and subjects

The study group was identified by retrospective review of medical records and pacemaker databases, and consisted of all patients with pacemakers followed at Children’s Hospital Boston from January 1980 to July 2002. Institutional Review Board approval was obtained prior to data collection. Patients whose initial device and/or lead implants were performed outside the study institution were included as long as subsequent pacing system follow-up was received at the study institution. Older

Patient characteristics

A total of 497 study patients were identified (Table 1). Median age at initial implant was 9.0 years (range 0–54.6 years), and 48% were female. In all, 117 patients (23%) were 18 years or older at initial implant. Median follow-up was 6.2 years (range 0.1–22.0). The majority of patients had structural congenital heart defects (68%), while 21% had primary electrical disease. Of the 339 patients who had undergone prior cardiac surgery, 28% had single ventricle physiology. The most common rhythm

Discussion

The choice of optimal pacemaker lead system requires careful assessment of the risks and benefits of each available option. As in adults, higher pacing thresholds and exit block often complicate epicardial lead use in children.17, 18 The advent of steroid-eluting epicardial leads has partially remedied these problems,10, 19, 20, 21, 22, 23 but epicardial systems require more extensive surgery. Transvenous leads, on the other hand, can result in vascular or valvular damage due to incongruity

Conclusions

In this large, longitudinal study of pacemaker recipients cared for at one pediatric and adult congenital heart disease center, we found a remarkably high incidence of lead failures. Younger children, those with congenital heart defects, and those with epicardial systems experienced lead failure earlier and more often. While the newer epicardial steroid-eluting leads have better longevity than non-steroid-eluting systems, their longevity remains significantly inferior to transvenous leads,

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Patient, procedural, and hardware factors associated with pacemaker lead failures in pediatrics and congenital heart disease

Abstract

Objectives

Background

Methods

Results

Conclusions

Section snippets

Design and subjects

Patient characteristics

Discussion

Conclusions

Am Heart J

Ann Thorac Surg

Cardiol Clin

J Am Coll Cardiol

Cardiac pacing in children and young adults

Am J Dis Child

Risks and benefits of cardiac pacing in children

Int J Cardiol

Pediatric electrophysiology

Curr Opin Cardiol

Cardiac pacing in infants and children

Cardiol Rev

Pediatric cardiac electrophysiology

Curr Opin Cardiol

Cardiac pacing in children

Curr Opin Cardiol

Permanent cardiac pacing in infants and children

Pacing Clin Electrophysiol

Endocardial pacemakers in childrenlead length and allowance for growth

Pacing Clin Electrophysiol

Trends in pediatric cardiac pacing

Can J Cardiol

Clinical experience of pacemaker treatment in children

Scand J Thorac Cardiovasc Surg

Twenty years experience with pediatric pacingepicardial and transvenous stimulation

Eur J Cardiothorac Surg