How to Handle Lead Problems in Pediatric & Congenital Heart Disease

Alpay Celiker MD.Acıbadem University

Department of Pediatric CardiologyIstanbul

16 year old boy with congenital AV block. VDD pacemaker . No complaintsECHO: Tricuspid valve problem. Some signs of left ventricular dysfunction

What to do???

Ways of Pacing

Transvenous Epicardial Hybrid

Epicardial & Transvenous Pacing Epicardial pacing

Better for preserving venous system Better results for long-term pacing

regarding pacing induced heart failure Applicable for all conditions More frequent lead problems

Transvenous pacing systemTransvenous pacing system Less lead problems More problems on venous system

Complications of Pacing System Infection;

Superficial, deep pocket Lead Endocarditis

Lead malfunction Fracture Insulation & other problems

Venous occlusionDamage to cardiovascular system

Pacing System InfectionLocalized or superficial infection

Localized pain, swellingPurulent discharge

Deep infectionFeverPurulent dischargePulmonary thromboembolismRecurrent pulmonary infectionSepsis

Pediatric Pacemaker Infections*

•Perioperative Infections (before discharge):

−Superficial 1,2 %Superficial 1,2 %−Deep 0,2 %

•Early Pacemaker Early Pacemaker Infections (< 60 days)Infections (< 60 days)

−Superficial 3,1 %−Deep 1,2 %

•Late Pacemaker Infections−Superficial 0,5 %−Deep 0,7 %

•Staphylococcus species were isolated in 44 %•Increased Risks

−ReinterventionReintervention−Down syndromeDown syndrome−Subcutaneous Subcutaneous preperitoneal pocketpreperitoneal pocket

* Cohen et al J Thorac Cardiovasc Surg 2002; 124.

Treatment Localized Infection

Intravenous and oral antibiotics Local debridman Infrequently pacing system removal

Deep Infection Pacing system removal Antibiotics

>2 weeks intravenously 6 weeks total

Treatment Choices

•Surgery−Large vegetations (> 10mm)−Abcess formation−Broken lead−Abandoned old leads−Concomitant surgery need

•Intervention− Small vegetations− Strand formation− Lead amenable to extraction

Lead Malfunction

Compromised pacing Failure to capture, high threshold Extra-cardiac stimulation

Compromised sensing Under-oversensing Lead-lead interaction

Electrical Abnormality Abnormal pacing impedance Abnormal high voltage impedance Low-amplitude electrogram

Signs of Lead Fracture

No stimuli or stimuli without capture

Oversensing of false signalsPermanent or intermittant high

lead impedance

Patient- and lead-related factors affecting lead fracture in children Olgun, Karagoz, Celiker and Ceviz

Europace (2008) 10, 844–847

Structural Problems

Conductor failureInsulation failureConnector failureFixation failure

Methods to Determine

Device interrogation ECG, marker channel, impedance, event

recording Imaging

X-ray, fluroscopyPhysical inspection or test at the

time of implant

Treatment of Malfunctioning LeadLead surgically abandoned or cappedLead electrically abandoned (mode

change)Lead explanted/repairedDevice reprogrammed (polarity)Lead related intervention: reposition,

partially abandone

Factors to Consider When Managing Leads

PatientPacemaker dependencePatient prognosisRisk of revision/replacement

procedureLead

Malfunction characteristicsAdverse clinical consequencceAvailability of reporogramming

Lead Extraction in Children.Why?

Remove the intravascular and intracardiac lead material

Relieve and reconstruct the venous access for the new leads

Prevent lead related infection

Indications Class I:Class I:

a: sepsis b: life-threatening arrhythmia c: life threatening condition d: thromboembolic event caused by

retained lead Obliteration of all useable veins Lead interfereres with the operation of

another device

Procedure

Basic lab tests and crossmatch for blood should be obtained

All x-rays related with pacemaker and leads must be evaluated

Arterial and venous catheters for BP monitor and fluid supply

Anesthesia

Lead Extraction Methods Simple traction Snares

Needles eye, Goose neck Lead locking devices

Cook, Spectranetrics Laser sheaths Radiofrequency sheaths Rotating sheaths

Pulleys & Weights

Locking Stylets

Spectranetics Lead Locking Device

Expanded

Compressed

Telescopic Sheaths

Laser Sheaths Rotating Sheaths

Classification of Complications

Major Complication Death Cardiac or vascular avulsion or tear Pulmonary embolism Stroke

Minor Complication Pericardial effusion or hemothorax Vascular repair need Pneumothorax requiring a chest tube Pulmonary embolism not requiring surgical

intervention

Definition of Success

Complete SuccessComplete Success - Removal of all lead material from the vascular space.

Partial SuccessPartial Success - Removal of all but a small portion of the lead.

FailureFailure – Abandoning a significant length of lead (more than 4cm)

Love CJLove CJ et al. PACEet al. PACE 2000;2000; 2323

Lead Problem nLead fracture 14Upgrade 8Infection 7Dislodgement 5Other reasons 5

Surgery for Lead Problems

InfectionLead can not be explanted by

interventional methodsLead should not be explanted

by interventional methodsConcomitant surgery need

New Problems !!!

Coronary sinus leads ICD leads Lumenless electrodes Multipl leads Venous obstruction Tricuspid valve impingement

Conclusions

Lead problems is frequent than in adult population

Although interventional methods have been successfull, surgery may be needed infrequently.

Newer techniques may offer more success and less complications.

Technologic improvement at epicardial and transvenous pacing may lower the incidence of lead problems.