Rehospitalizations for complications and mortality following pacemaker implantation: A retrospective cohort study in an older population

Dual-chamber versus single chamber pacemakers, a systemic review and meta-analysis on sick sinus syndrome and atrioventricular block patients

Aims

The atrioventricular block (AVB) is a conduction system problem that results from the impairment in the transmission of an impulse from the atria to the ventricle, the disease has many etiologies. This article aimed to evaluate the efficacy and safety of dual and single-chamber pacemakers in patients with SSS and AVB.

Methods

An electronic search of PubMed (Medline), EMBASE, and Google Scholar was performed from 2000 till August 15th, 2022. Retrieved articles were exported to Endnote Reference Library Software, where duplicate studies were removed from the list, and only articles meeting the eligibility criteria of this study were selected. RevMan 5.4 and STATA 16 software were used for the analysis. The modified Cochrane Collaboration's risk of bias and New-castle Ottawa scale were used for quality assessment of RCTs and observational studies respectively.

Results

This study is composed of 8953 patients with sick-sinus syndrome and atrioventricular block. A total of thirteen outcomes are included in this meta-analysis, out of which atrial fibrillation significantly favored dual chamber [OR = 1.29; 95 % CI = 1.05-1.59; P = 0.01 I2 = 29 %] and overall complications [OR = 0.48; 95 % CI = 0.29-0.77; p = 0.03 I2 = 0 %] and pneumothorax [OR = 0.31; 95 % CI = 0.10-0.93; p = 0.04, I2 = 0 %] were satisfied by single-chamber pacing.

Conclusion

This study concluded that neither single-chamber nor dual-chamber pacemakers are superior to each other, but they are unique in their own ways as the results of this study manifest remarkable reduction in atrial fibrillation rates and pneumothorax using dual-chamber and single-chamber pacemakers respectively.

Conductive bacterial cellulose: From drug delivery to flexible electronics

Bacterial cellulose (BC) is a chemically pure, non-toxic, and non-pyrogenic natural polymer with high mechanical strength and a complex fibrillar porous structure. Due to these unique biological and physical properties, BC has been amply used in the food industry and, to a somewhat lesser extent, in medicine and cosmetology. To expand its application the BC structure can be modified. This review presented some recent developments in electrically conductive BC-based composites. The as-synthesized BC is an excellent dielectric. Conductive polymers, graphene oxide, nanoparticles and other materials are used to provide it with conductive properties. Conductive bacterial cellulose (CBC) is currently investigated in numerous areas including electrically conductive scaffolds for tissue regeneration, implantable and wearable biointerfaces, flexible batteries, sensors, EMI shielding composites. However, there are several issues to be addressed before CBC composites can enter the market, namely, composite mechanical strength reduction, porosity decrease, change in chemical characteristics. Some of them can be addressed both at the stage of synthesis, biologically, or by adding (nano)materials with the required properties to the BC structure. We propose several solutions to meet the challenges and suggest some promising BC applications.

Network pharmacology and LC-MS approachs to explore the active compounds and mechanisms of Yuanjiang decoction for treating bradyarrhythmia

BACKGROUND

Yuanjiang decoction (YJD), a traditional Chinese medicinal prescription, has been found to have a significant heart rate-increasing effect and is effective in the treatment of symptomatic bradyarrhythmia in previous studies. However, its specific components and potential mechanisms remain unclear.

METHODS

In this study, we detected and identified the main compounds of YJD using liquid chromatography-mass spectrometry (LC-MS). Through the approach of network pharmacology, we predicted the core targets of the active components, bradyarrhythmia targets, and obtained potential anti-bradyarrhythmia targets of YJD. We further performed protein to protein interaction (PPI), gene ontology (GO) enrichment analyses and kyoto encyclopedia of genes and genomes (KEGG) signaling pathway analyses for core targets, and constructed network of key active ingredients-core targets of YJD. Finally, molecular docking and molecular dynamics simulation were performed for key active ingredients and core targets.

RESULTS

The YJD contains a total of 35 main chemical components. The key active ingredients-core targets network contains 36 nodes and 90 edges, including 20 key active ingredients and 16 core targets. The core targets in the PPI network were TP53, TNF, HRAS, PPARG, IL1B, KCNH2, SCN5A, IDH1, LMNA, ACHE, F2, DRD2, CALM1, KCNQ1, TNNI3, IDH2 and TNNT2. KEGG pathway analysis showed that YJD treatment of bradyarrhythmia mainly involves neuroactive ligand-receptor interaction, adrenergic signaling in cardiomyocytes, cAMP signaling pathway, calcium signaling pathway, cholinergic synaptic and serotonergic synapse signaling pathway. The biological processes mainly include regulation of hormone levels, regulation of cardiac contraction, chemical synaptic transmission, circadian rhythm, positive regulation of heart rate, smooth muscle contraction, response to metal ion, oxidation-reduction process, neurotransmitter transport and import across plasma membrane. Molecular docking and molecular dynamics simulation results showed that hesperidin and tetrahydropalmatine had higher affinity with DRD2 and KCNQ1, respectively.

CONCLUSION

This study reveals the pharmacodynamic material basis of YJD and its potential multicomponent-multitarget-multipathway pharmacological effects, predicted its potential anti-bradyarrhythmia mechanism may be related to the regulation of myocardial autonomic nervous function and related ion channels. Our work demonstrates that YJD has great potential for treating bradyarrhythmias as a complementary medicine, and the results can provide a theoretical basis for the development and clinical application of YJD.

Long-Term Implications of Pacemaker Insertion in Younger Adults: A Single Centre Experience

BACKGROUND

The long-term implications of pacemaker insertion in younger adults are poorly described in the literature.

METHODS

We performed a retrospective analysis of consecutive younger adult patients (18-50 yrs) undergoing pacemaker implantation at a quaternary hospital between 1986-2020. Defibrillators and cardiac resynchronisation therapy devices were excluded. All clinical records, pacemaker checks and echocardiograms were reviewed.

RESULTS

Eighty-one (81) patients (median age 41.0 yrs IQR=35-47.0, 53% male) underwent pacemaker implantation. Indications were complete heart block (41%), sinus node dysfunction (33%), high grade AV block (11%) and tachycardia-bradycardia syndrome (7%). During a median 7.9 (IQR=1.1-14.9) years follow-up, nine patients (11%) developed 13 late device-related complications (generator or lead malfunction requiring reoperation [n=11], device infection [n=1] and pocket revision [n=1]). Five (5) of these patients were <40 years old at time of pacemaker insertion. At long-term follow-up, a further nine patients (11%) experienced pacemaker-related morbidity from inadequate lead performance managed with device reprogramming. Sustained ventricular tachycardia was detected in two patients (2%). Deterioration in ventricular function (LVEF decline >10%) was observed in 14 patients (17%) and seven of these patients required subsequent biventricular upgrade. Furthermore, four patients (5%) developed new tricuspid regurgitation (>moderate-severe). Of 69 patients with available long-term pacing data, minimal pacemaker utilisation (pacing <5% at all checks) was observed in 13 (19%) patients.

CONCLUSIONS

Pacemaker insertion in younger adults has significant long-term implications. Clinicians should carefully consider pacemaker insertion in this cohort given risk of device-related complications, potential for device under-utilisation and issues related to lead longevity. In addition, patients require close follow-up for development of structural abnormalities and arrhythmias.

Compassionate Use of Yuanjiang Decoction, a Traditional Chinese Medicinal Prescription, for Symptomatic Bradyarrhythmia

Background: No effective medication is available for symptomatic bradyarrhythmia, particularly in low socioeconomic status (SES) population.

Objective: To explore the safety and efficacy of Yuanjiang decoction, a traditional Chinese medicinal prescription, for symptomatic bradyarrhythmia on a compassionate-use basis.

Methods: This compassionate-use study was conducted in Beijing, China between January 2019 and January 2020. Eligible participants were recruited and treated with Yuanjiang decoction (composed of 6 Chinese herbal medicines), 200 ml twice daily for 16 weeks. Analyses were done with the intention-to-treat (ITT) approach. The primary outcome measure was the proportion of participants who achieved a favorable treatment outcome at 16 weeks.

Results: As of January 2020, 184 patients were included. After 16-weeks treatment, 12 participants were lost to contact while 21 participants were terminated from this study, with a drop-out rate of 17.93%. The most common treatment-related adverse events were xerostomia (6.52%), constipation (6.45%) and sleepiness (3.26%). The proportion of participants with favorable treatment outcome was 65.22% at 4 weeks, 59.78% at 8 weeks (OR: 1.11, 95% CI: 0.71–1.73), 61.41% at 12 weeks (OR: 1.16, 95% CI: 0.92–1.45) and 60.87% at 16 weeks (OR: 1.15, 95% CI: 0.98–1.35). In the multifactor regression analysis, the favorable treatment outcome at 16 weeks was significantly associated with completing at least 8 weeks treatment (OR: 2.053, 95% CI: 1.064–3.560), while unfavorable treatment outcome was significantly associated with an atrioventricular block (OR: 0.255, 95% CI: 0.083–0.784), current smoking (OR: 0.343, 95% CI: 0.027–0.487), and syncope in the month before treatment (OR: 0.321, 95%CI: 0.114–0.904).

Conclusion: This compassionate-use study showed encouraging outcomes of treatment with Yuanjiang decoction, without serious adverse events. This study identified several key factors that may affect outcomes. These findings helped inform the design and assess the feasibility of a large-scale randomized clinical trial.

Lead Perforation Into the Left Internal Mammary Artery Causing Circulatory Collapse After Pacemaker Insertion

A 66-year-old woman underwent a pacemaker implantation following a symptomatic pause. The pacemaker lead inadvertently punctured the ventricle during implantation, penetrating through to the left internal mammary artery, causing slow hemorrhage. There was subsequent circulatory collapse with shock. We describe this rare yet life-threatening condition. (Level of Difficulty: Intermediate.)

Immediate and long-term need for permanent cardiac pacing following aortic valve replacement

Introduction: Atrioventricular (AV) node conduction disturbances are common following surgical aortic valve replacement (SAVR), and in some cases the patient needs a permanent pacemaker (PPM) implantation before discharge from hospital. Little is known about the long-term need for PPM and the PPM dependency of these individuals. We determined the incidence of PPM implantation before and after discharge in SAVR patients. Methods: We studied 557 consecutive patients who underwent SAVR for aortic stenosis in Iceland between 2002 and 2016. Timing and indication for PPM were registered, with a new concept, ventricular pacing proportion (VPP), defined as ventricular pacing ≥90% of the time, being used to approximate pacemaker dependency. The median follow-up time was 73 months. We plotted the cumulative incidence of pacemaker implantation, treating death as a competing risk. Results: Of the 557 patients, 22 (3.9%) received PPM in the first 30 days after surgery, most commonly for complete AV block (n = 14) or symptomatic bradycardia (n = 8); Thirty-eight other patients (6.8%) had a PPM implanted >30 days postoperatively, at a median of 43 months after surgery (range 0‒181), most often for AV block (n = 13) or sick-sinus syndrome (n = 10). The cumulative incidence of PPM implantation at 1, 5, and 10 years postoperatively was 5.0%, 9.2%, and 12.3%, respectively. During follow-up, 45.0% of the 60 patients had VPP ≥90%. Conclusion: The cumulative incidence of permanent pacemaker implantation following SAVR was about 12% at 10 years, with every other patient having VPP ≥90% during follow-up. This suggests that AV node conduction disturbances extend significantly beyond the perioperative period.

Safety of Permanent Pacemaker Implantation: A Prospective Study

Although pacemaker implantation is considered to be low risk, it is not exempt from complications and technical failures during the procedure, both in the short and long term, and the complications that such patients may present remain unknown. The aim has been to analyze the complication rates associated with permanent pacing and to identify if these differ between patients with or without previous antithrombotic therapy. We used a prospective, single center, observational study of 310 adult patients with indications of permanent pacing. They were hospitalized from 1 January to 31 December 2014 and followed up for 6 months after the pacemaker implant. The participants were distributed into two groups according to the antithrombotic therapy prior to the implant. The most frequent major complications were pneumothorax (3.87%) and lead dislodgement (8.39%), while superficial phlebitis (12.90%) and uncomplicated hematomas (22.58%) were presented as the most recurrent minor complications. Hematomas were the most frequent minor complication in the antithrombotic therapy cohort, and shoulder pain was reported as the most recurrent minor complication in the non-exposed group. Finding out about complications in pacemaker implants enables a complete view of the process, and hence the prioritization of actions aimed at improving safety and reducing associated risks.

Rehospitalizations for complications and mortality following pacemaker implantation: A retrospective cohort study in an older population

INTRODUCTION

A large number of older people receive pacemakers each year but broad population-based studies that describe complications following pacemaker implantation in this population are lacking.

METHODS

We conducted a retrospective cohort study using data from the Australian Government Department of Veterans' Affairs database. The cohort consisted of patients who received a pacemaker from 2005 to 2014. The outcomes were subsequent rehospitalizations for infections, procedure-related complications, thromboembolism, cardiovascular events (heart failure, myocardial infarction, and atrial fibrillation), and reoperation of pacemaker, and mortality.

RESULTS

There were 10 883 pacemakers recipients, the median age was 86 years (interquartile range 83-89), 61% were males, and 74% received a dual-chamber pacemaker. Within 90 days postdischarge, rehospitalizations were occasioned by pacemaker infection in 0.5%, device-related complications in 1.5%, cerebral infarction in 0.7%, and heart failure in 6% of single-chamber pacemaker recipients. In dual-chamber pacemaker recipients rehospitalizations were occasioned by pacemaker infection in 0.4%, septicemia in 0.4%, device-related complications in 1.2%, cerebral infarction in 0.3%, and heart failure in 3%. Rehospitalizations for pacemaker adjustment occurred in 1.5% of patients. The 90-day postdischarge mortality was 5% and 3% in patients with single- and dual-chamber pacemaker, respectively.

CONCLUSION

Rehospitalizations for infection, procedure-related complications, or thromboembolism occurred in 1% to 2% of patients within 90 days postdischarge, while 10% of single chamber and 7% of dual-chamber recipients experienced a rehospitalization for a cardiovascular event.