Surgical Outcomes of Permanent Epicardial Pacing in Neonates and Young Infants Less Than 1 Year of Age

Percutaneous epicardial pacing in infants using direct visualization: A feasibility animal study

BACKGROUND

Pacemaker implantation in infants and small children is limited to epicardial lead placement via open chest surgery. We propose a minimally invasive solution using a novel percutaneous access kit.

OBJECTIVE

To evaluate the acute safety and feasibility of a novel percutaneous pericardial access tool kit to implant pacemaker leads on the epicardium under direct visualization.

METHODS

A custom sheath with optical fiber lining the inside wall was built to provide intrathoracic illumination. A Veress needle inside the illumination sheath was inserted through a skin nick just to the left of the xiphoid process and angled toward the thorax. A needle containing a fiberscope within the lumen was inserted through the sheath and used to access the pericardium under direct visualization. A custom dilator and peel-away sheath with pre-tunneled fiberscope was passed over a guidewire into the pericardial space via modified Seldinger technique. A side-biting multipolar pacemaker lead was inserted through the sheath and affixed against the epicardium.

RESULTS

Six piglets (weight 3.7-4.0 kg) had successful lead implantation. The pericardial space could be visualized and entered in all animals. Median time from skin nick to sheath access of the pericardium was 9.5 (interquartile range [IQR] 8-11) min. Median total procedure time was 16 (IQR 14-19) min. Median R wave sensing was 5.4 (IQR 4.0-7.3) mV. Median capture threshold was 2.1 (IQR 1.7-2.4) V at 0.4 ms and 1.3 (IQR 1.2-2.0) V at 1.0 ms. There were no complications.

CONCLUSION

Percutaneous epicardial lead implantation under direct visualization was successful in six piglets of neonatal size and weight with clinically acceptable acute pacing parameters.

Permanent epicardial pacing in neonates and infants less than 1 year old: 12-year experience at a single center

BACKGROUND

Permanent epicardial pacing is the primary choice for neonates and infants with bradyarrhythmia. We reviewed mid-term outcomes after epicardial permanent pacemaker (EPPM) implantation in this age group.

METHODS

From Dec 1, 2008 to Dec 1, 2019, children who underwent EPPM implantation within the first year of life were included in our study. Patients were followed up for as long as 12 years, until Jun 11, 2021, for all-cause mortality and pacemaker reoperation. Kaplan-Meier and log-rank tests were used for analysis.

RESULTS

Of 31 consecutive patients [18 boys (58.1%) and 2 neonates (6.5%)] included in this study, 30 (96.8%) were discharged alive and assessed at a median follow-up of 3.9 years [interquartile range (IQR) 4.7]. The median age and weight of the patients were 156 days (IQR 217) and 5.3 kg (IQR 3.5), respectively, at the time of their operation. Twenty-five (80.6%) patients had congenital heart disease, and the main indication for pacing was postoperative atrioventricular block (AVB) in 21 (67.7%) patients. During follow-up, 3 (9.7%) patients died and there were a total of 9 pacing lead failures in 7 (22.6%) patients. The median longevity of leads (unipolar steroid-eluting) was 2.9 years (IQR 3.6). Freedom from lead reoperation was 90.3%, 72.0%, 65.5% and 49.1% at 1, 3, 5, and 8 years, respectively. The median longevity of the pacing generators was 3.3 years (IQR 2.8). Freedom from generator reoperation was 90.3%, 75.6%, 52.4% and 43.6% at 1, 3, 5 and 6 years, respectively.

CONCLUSIONS

The mid-term outcome of EPPM implantation in neonates and infants was acceptable. Neonates and infants with EPPM implants face the risk of repeated reoperations and all-cause death. A patient's prognosis can depend on regular follow-up, type of pacing lead and the presence of congenital heart malformations, especially complex congenital heart disease.

Etiology and device therapy in complete atrioventricular block in pediatric and young adult population: Contemporary review and new perspectives

Complete atrioventricular block (CAVB) is a total dissociation between the atrial and ventricular activity, in the absence of atrioventricular conduction. Several diseases may result in CAVB in the pediatric and young-adult population. Permanent right ventricular (RV) pacing is required in permanent CAVB, when the cause is neither transient nor reversible. Continuous RV apical pacing has been associated with unfavorable outcomes in several studies due to the associated ventricular dyssynchrony. This study aims to summarize the current literature regarding CAVB in the pediatric and young adult population and to explore future treatment perspectives.

Modern Technology for Prevention of Sudden Cardiac Death – a Clinical Update on Device Therapy in Children with Congenital Heart Diseases

Sudden cardiac death in children is one of the most devastating conditions that can be encountered in acute cardiac care. Intracardiac device therapy, providing prompt and effective treatment in malignant ventricular arrhythmia or in severe conduction abnormalities, is a promising tool to reduce the incidence of this fatal condition. However, the implementation of device-based therapy in the pediatric population is currently limited by the lack of clinical studies on large number of subjects. As a result, indications for device therapy in pediatric patients are still unclear in many circumstances. There are also several particularities related to device implantation in pediatric age, such as the somatic growth leading to a mismatch between chamber size and lead length, or the difficulties of implantation technique in children with small body weight. This study aims to present an update on the current advantages and limitations of device-based therapy for treating severe malignant arrhythmia or conduction disorders in children at risk for sudden cardiac death.