The Placement of Atrial Pacing Leads in Patients after Cardiac Surgery

Dept. of Cardiology, First Affiliated Hospital, Nanjing Medical University

Jiangang Zou, M.D.; Ph.D.

Introduction

• The incidence of AVB and SND following

open-heart surgery for congenital heart

disease: 1%~4%

• The incidence of bradyarrhythmias after

cardiac transplantation varies from 8% to 23%

• The experience of the permanent pacing after

open-heart surgery is rare

• The placement of atrial pacing leads

Circulation 2008,117:e350-e408

Recommendations for permanent pacing in children, adolescents, and patients with congenital heart disease

Recommendations for permanent pacing in children, adolescents, and patients with congenital heart disease

Recommendation for pacing after cardiac transplantation

The implantation of pacing leads

• Transvenous:

Cephelic/subclavian puncture/active lead

• Epicardial:

small body size

Fontan-type procedures

tricuspid valve replacement

• The placement of atrial pacing leads

Europace 2007,9:426-31

EPI: 18% OF ATRIAL LEADS, 24% OF VENTRICULAR LEADS

ENDO: 5% OF VENTRICULAR LEADS

Lead failures:

Single-lead, VVIR ENDO pacing had higher efficiency and safety than EPI.

Ann Thorac Surg. 2008;85(5):1704-11

• 239 bipolar steroid-eluting epicardial leads in 114 cases

• 12-year follow-up

• Average atrial and ventricular threshold:1.2V/0.5ms

Thresholds of LA and RA: 0.82V/0.5ms and 0.74V/0.5ms

Thresholds of LV and RV: 0.96V/0.5ms and 0.94V/0.5ms

P sensing of LA and RA: 3.4mV and 2.9mV

V sensing of LV and RV: 11.2mV and 7.7mV

• Lead failure: 19(8%)

• Lead survival at 2 and 5 year :

99% and 94% for atrial leads

96% and 85% for ventricular leads

Bipolar steroid-eluting epicardial leads demonstrate excellent sensing characteristics and persistent low pacing threshold

Eur J Cardiothorac Surg 2000;17:455-461

• Transvenous pacing in the pediatric

population is associated with a lower

threshold and lower rate of lead-related

complications

• If EPI lead necessary, steroid-eluting

leads recommended

J Thorac Cardiovasc Surg 1999;117:523-528

• Lead failure: 4 (epi) vs 4 (endo)

• Lead survival at 2 year: 91% (epi) vs 87% (endo)

• Steroid-eluting epi leads have the same

longevity as the conventional endo lead

• Pacing and sensing are similar

• Steroid-eluting epi leads are good alternatives

for endo leads for small children

PACE 2009:32:779-785

Compared to epi lead, transvenous atrial

pacing lead may be placed in Fontan patients

with lower procedure morbidity and

expectation of lead performance and

longevity.

• 3 DDD cases after surgery

• atrial lead characteristics: sensing threshold impedance lead

pt.1 at impant(17y) 4.5mv 0.6V/0.4ms 650 passive

follow-up(4y) 2.5mv no capture 680

pt.2 at impant(34y) 2.2mv 0.5V/0.4ms 720 active

follow-up(41y) 2.0mv 0.5V/0.4ms 700

pt.3 at impant(14y) 3.0mv 1.0V/0.4ms 690 active

follow-up(3y) 2.5mv 1.2V/0.4ms 720

conclusions

• The placement of atrial lead: endocardial and epicardial• Endocardial: screw-in, older children• Epicardial: steroid-eluting lead recommended small body size Fontan-type procedures tricuspid valve replacement• Follow-up

Thanks for your attention!