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.

Smart Drug Release from Medical Devices

Medical devices are becoming key players on health monitoring and treatment. Advances in materials science and electronics have paved the way to the design of advanced wearable, insertable, and implantable medical devices suitable for the prevention and cure of diseases and the physical or functional replacement of damaged tissues or organs. However, intimate and prolonged contact of the medical devices with the human body increases the risks of adverse foreign-body reactions and biofilm formation. Drugs can be included in/on the medical device not only to minimize the risks but also to improve the therapeutic outcomes. Drug-eluting medical devices can deliver the drug in the place where it is needed using lower doses and avoiding systemic effects. Drug-device combination products that release the drug following preestablished rates have already demonstrated their clinical relevance. The aim of this mini-review is to bring attention to medical devices that can actively regulate drug release as a function of tiny changes in their environment, caused by the pathology itself, microorganisms adhesion or some external events. Thus, endowing medical devices with stimuli-responsiveness should allow for precise, on-demand, regulated release of the ancillary drugs to expand the therapeutic performance of the medical device and also should serve as a first step to offer personalized solutions to each patient. Main sections deal with smart drug-eluting medical devices that are sensitive to infection-related stimuli, natural healing processes, mechanical forces, electric fields, ultrasound, near-infrared radiation, or chemicals such as vitamin C.

The development of pacing induced ventricular dysfunction is influenced by the underlying structural heart defect in children with congenital heart disease

Background

Right ventricular pacing can cause pacing-induced ventricular dysfunction (PIVD) correctable with biventricular pacing (BiVP). Factors associated with PIVD are poorly understood.

Methods

We reviewed children receiving epicardial dual-chamber pacemakers for complete heart block (CHB) after congenital heart disease (CHD) surgery. PIVD was defined as% fractional shortening <15% improving after BiVP.

Results

Between 2005 and 2014, 47 children <2 years developed CHB after CHD surgery. All had biventricular hearts and underwent epicardial dual chamber pacemaker implantation. Nine of the 47 (19%) developed PIVD. PIVD occurred in 0/10 with ventricular septal defect (VSD), 0/6 with tetralogy of Fallot, 2/6 with double outlet right ventricle, 2/6 with transposition and VSD, 3/9 with atrioventricular canal defect, 1/2 with mitral valve replacement; 1/3 with congenitally corrected TGA repair; and 0/3 with atrioventricular canal plus tetralogy of Fallot and 0/1 with subaortic membrane. QRS duration (QRSD) was 84–170 (median 135 ms) in the non PIVD group and 100–168 (median 124) ms in the PIVD group. Percentage fractional shortening (%FS) while paced was 16–46, median 30% in the non-PIVD group and 6–15 (median 11%) in the PIVD group.%FS post upgrade to BiVP (with an epicardial LV lead) in the 9 patients with PIVD was 23–33 (median 29%).

Conclusions

PIVD occurred in certain CHD but not others. Prolonged QRSD was not associated with PIVD. The predilection for RV pacing to result in PIVD in certain types of CHD needs further study.