the placement of atrial pacing leads in patients after cardiac surgery dept. of cardiology, first...
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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.
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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
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Circulation 2008,117:e350-e408
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Recommendations for permanent pacing in children, adolescents, and patients with congenital heart disease
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Recommendations for permanent pacing in children, adolescents, and patients with congenital heart disease
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Recommendation for pacing after cardiac transplantation
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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
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Europace 2007,9:426-31
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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.
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Ann Thorac Surg. 2008;85(5):1704-11
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• 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
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Bipolar steroid-eluting epicardial leads demonstrate excellent sensing characteristics and persistent low pacing threshold
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Eur J Cardiothorac Surg 2000;17:455-461
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• 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
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J Thorac Cardiovasc Surg 1999;117:523-528
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• Lead failure: 4 (epi) vs 4 (endo)
• Lead survival at 2 year: 91% (epi) vs 87% (endo)
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• 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
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PACE 2009:32:779-785
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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.
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• 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
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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
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Thanks for your attention!