Transvenous Pacing in Infants and Children With Congenital Heart Disease Henry M. Spotnitz, MD Columbia Presbyterian Medical Center, New York, New York
A technique for transvenous pacemaker implantation in children with complex heart disease is described. The use of small positive-fixation leads, introducers, retained guidewires, and atrial lead loops to allow for growth all have an important role in management of this often challenging problem. (Ann Thoruc Surg 1990;49:495-6)
P
ostoperative heart block is a recognized complication of repair of congenital heart disease, resulting in high mortality unless permanent pacing is established [ 11. Although epicardial pacing is often useful in this setting, transvenous pacing is a desirable alternative either as a primary means of therapy or for replacement of failed epicardial leads 121. Recent improvements both in technique and in design of leads, introducers, and pacemaker generators allow transvenous pacing to be established consistently despite congenital malformation of the heart and great vessels.
Material and Methods General anesthesia, maintenance of heart rate with drugs or temporary pacing, excellent fluoroscopy, and electrocardiographic monitoring are minimum requirements. A cephalic or other small venous branch is exposed through a 3- to 4-cm incision beneath the left clavicle. A flexible guidewire is introduced through a small venotomy and passed centrally under fluoroscopic control. A 7F stripaway percutaneous catheter introducer (model 405108, Daig Corp, Minnetonka, MN) is passed over the wire and used to introduce a unipolar, positive fixation, screw-in permanent pacing electrode (model 435-02, Intermedics, Inc, Freeport, TX) (Fig 1). If dual-chamber pacing is required, the guidewire is reintroduced through the introducer before the introducer is removed. A hemostatic pursestring suture is also placed around the vein remnant or pectoralis muscle before the introducer is removed. The guidewire is clamped to the drapes to prevent its migration while the first lead is introduced into the right ventricle by standard techniques. A generous loop of extra lead is advanced into the right atrium after the stylet is removed from the lead to allow for patient growth (Fig 2). Adequacy of R-wave amplitude and pacing thresholds is confirmed. If an atrial lead is also needed, the ventricular lead is Accepted for publication Nov 30, 1989 Address reprints to Dr Spotnitz, 630 W 168th St, New York, NY
0 1990 by The Society of Thoracic Surgeons
10032.
marked with a free tie at the generator end and also tied into position, using the securing sleeve at the entry site. The stylet is reintroduced into only the subclavian portion of the ventricular lead to stiffen it against migration during introduction of the atrial lead, and the ventricular lead is held securely at the venous entry site by an assistant, also to prevent migration. A second 7F stripaway introducer is passed over the guidewire previously left in the vein and the second lead is introduced, tested, and positioned, leaving redundant lead to allow for growth. A hemostatic subcutaneous pocket is fashioned, and the leads are attached to a small unipolar generator, with function confirmed by electrocardiographic analysis and lead position by repeat fluoroscopy before the patient is undraped and awakened.
Comment The use of guidewires, strip-away introducers, and positive fixation leads in transvenous pacing has been well described [>5]. These methods are particularly useful for the specific problem of transvenous pacing in congenital heart disease, for which subclavian puncture is potentially hazardous. Anatomical problems in these patients include persistent left superior vena cava (see Fig 2) as well as venous thrombosis related to previous operations or use of central lines for monitoring or nutrition. The retained guidewire technique [6] can also be used with direct subclavian puncture, but use of a small peripheral vein to introduce the guidewire can avoid the hazards of subclavian puncture [5]. Unipolar leads and generators require additional care to limit oversensing and pectoralis or diaphragmatic pacing, but unipolar construction allows use of a lead with a very small cross-section (see Fig 1).Small lead size permits use of small introducers, increased lead flexibility, and less venous obstruction. The positive-fixation feature permits unusual intraventricular locations (Fig 3) and redundant lead loops (see Figs 2, 3). The 435-02 lead design includes permanent exposure of the fixation coil. This requires some experience to avoid snagging on chordae tendineae and other obstacles on the path to the right ventricle. Although leads with retractable fixation coils are available, this feature results in a larger lead tip and heavier lead shaft. Bipolar positive-fixation leads are relatively stiff and more cumbersome to use in infants and small children. We have not used these methods in newborn or premature infants in whom access through the external jugular vein and removal of the stylet during lead manipulation are likely to be useful modifications. The smallest 0003-4975/90/$3.50
496
HOW TO DO IT SPOTNITZ PACING IN CONGENITAL HEART DISEASE
Ann Thorac Surg 1990;49:495-6
Fig 1 . Positive-fixation, screw-in lead has polyurethane insulation, small cross-section, and a permanently extended fixation coil. Counterclockwise rotation minimizes "hang-ups" during insertion.
pacemaker generators currently available are satisfactory for subcutaneous sites, except in small infants. Redundant right atrial lead loops should allow for 5 to 10 years of growth in these patients (Gheissari A and Spotnitz HM, unpublished data). The techniques described have been used in 2 infants (aged 9 and 12 months) and 13 children (aged 3, 3, 5, 5, 5, 6, 6, 7, 7, 8, 9, 9, and 10 years) at the Columbia-Presbyterian Medical Center since October 1985 with no complications or need for reoperation. In adults, 342 endocardial screw-in leads have been used, with no ventricular lead displacement. The atrial lead displacement rate in adults has been 3%. No perfect method of long-term pacing has been demonstrated, and both exit block and lead displacement can be anticipated in the younger population as our experience increases. It
Fig 3 . Ventricular inhibited pacemaker inserted in a 6-year-old child ioith corrected transposition for sick sinus syndrome after closure of an atrial septa1 defect. The lead is placed high in the outflow tract of the right vcntricle to prevent diaphragmatic pacing, zohich zoas observed from locations closer to the apex. A generotis lead loop alloius for groicith. Lead loops mid outflow tract pacing are likely to result in lead displacement unless positiire fixation leads are used.
is hoped that this description will improve the results of transvenous pacing in this often challenging group of patients.
References
Fig 2 . Transvenous dual-chamber demand pacemaker inserted in October 1985 in a 3-year-old child for complete heart block after niitral valve replacement. The leads enter the heart through the left superior vena cava and the coronary sinus. Lead loops provide extra length to allow for groruth. A longer loop for the atrial lead zuould be preferable but u ~ a sprevented by the location of entry into the right atrium.
1. Lillehei CW, Sellers RD, Bonnabeau RC Jr, Elliot RS. Chronic postsurgical complete heart block: with particular reference to prognosis, management, and a new P-wave pacemaker. J Thorac Cardiovasc Surg 1963;46:43&56. 2. Walsh CA, McAlister HF, Andrews CA, Steeg CN, Eisenberg R, Furman S. Pacemaker implantation in children: a 21 year experience. PACE 1988;11:194O-4. 3. Belott PH. Implantation techniques: new developments. In: Barold S, Mugica J, eds. New perspectives in cardiac pacing. Mount Kisco, NY: Futura, 1988;255-77. 4. Ong LS, Barold S, Lederman M, et al. Cephalic vein guide wire technique for implantation of permanent pacemakers. Am Heart J 1987;114:753-6. 5. Littleford PO, Parsonnet V, Specor SD. Method for the rapid and atraumatic insertion of permanent endocardial pacemaker electrodes through the subclavian vein. Am J Cardiol 1979; 43:980-2. 6. Belott PH. A variation on the introducer technique for unlimited access to the subclavian vein. PACE 1981;4:43-8.
A technique for transvenous pacemaker implantation in children with complex heart disease is described. The use of small positive-fixation leads, introducers, retained guidewires, and atrial lead loops to allow for growth all have an important role in management of this often challenging problem. (Ann Thoruc Surg 1990;49:495-6)
P
ostoperative heart block is a recognized complication of repair of congenital heart disease, resulting in high mortality unless permanent pacing is established [ 11. Although epicardial pacing is often useful in this setting, transvenous pacing is a desirable alternative either as a primary means of therapy or for replacement of failed epicardial leads 121. Recent improvements both in technique and in design of leads, introducers, and pacemaker generators allow transvenous pacing to be established consistently despite congenital malformation of the heart and great vessels.
Material and Methods General anesthesia, maintenance of heart rate with drugs or temporary pacing, excellent fluoroscopy, and electrocardiographic monitoring are minimum requirements. A cephalic or other small venous branch is exposed through a 3- to 4-cm incision beneath the left clavicle. A flexible guidewire is introduced through a small venotomy and passed centrally under fluoroscopic control. A 7F stripaway percutaneous catheter introducer (model 405108, Daig Corp, Minnetonka, MN) is passed over the wire and used to introduce a unipolar, positive fixation, screw-in permanent pacing electrode (model 435-02, Intermedics, Inc, Freeport, TX) (Fig 1). If dual-chamber pacing is required, the guidewire is reintroduced through the introducer before the introducer is removed. A hemostatic pursestring suture is also placed around the vein remnant or pectoralis muscle before the introducer is removed. The guidewire is clamped to the drapes to prevent its migration while the first lead is introduced into the right ventricle by standard techniques. A generous loop of extra lead is advanced into the right atrium after the stylet is removed from the lead to allow for patient growth (Fig 2). Adequacy of R-wave amplitude and pacing thresholds is confirmed. If an atrial lead is also needed, the ventricular lead is Accepted for publication Nov 30, 1989 Address reprints to Dr Spotnitz, 630 W 168th St, New York, NY
0 1990 by The Society of Thoracic Surgeons
10032.
marked with a free tie at the generator end and also tied into position, using the securing sleeve at the entry site. The stylet is reintroduced into only the subclavian portion of the ventricular lead to stiffen it against migration during introduction of the atrial lead, and the ventricular lead is held securely at the venous entry site by an assistant, also to prevent migration. A second 7F stripaway introducer is passed over the guidewire previously left in the vein and the second lead is introduced, tested, and positioned, leaving redundant lead to allow for growth. A hemostatic subcutaneous pocket is fashioned, and the leads are attached to a small unipolar generator, with function confirmed by electrocardiographic analysis and lead position by repeat fluoroscopy before the patient is undraped and awakened.
Comment The use of guidewires, strip-away introducers, and positive fixation leads in transvenous pacing has been well described [>5]. These methods are particularly useful for the specific problem of transvenous pacing in congenital heart disease, for which subclavian puncture is potentially hazardous. Anatomical problems in these patients include persistent left superior vena cava (see Fig 2) as well as venous thrombosis related to previous operations or use of central lines for monitoring or nutrition. The retained guidewire technique [6] can also be used with direct subclavian puncture, but use of a small peripheral vein to introduce the guidewire can avoid the hazards of subclavian puncture [5]. Unipolar leads and generators require additional care to limit oversensing and pectoralis or diaphragmatic pacing, but unipolar construction allows use of a lead with a very small cross-section (see Fig 1).Small lead size permits use of small introducers, increased lead flexibility, and less venous obstruction. The positive-fixation feature permits unusual intraventricular locations (Fig 3) and redundant lead loops (see Figs 2, 3). The 435-02 lead design includes permanent exposure of the fixation coil. This requires some experience to avoid snagging on chordae tendineae and other obstacles on the path to the right ventricle. Although leads with retractable fixation coils are available, this feature results in a larger lead tip and heavier lead shaft. Bipolar positive-fixation leads are relatively stiff and more cumbersome to use in infants and small children. We have not used these methods in newborn or premature infants in whom access through the external jugular vein and removal of the stylet during lead manipulation are likely to be useful modifications. The smallest 0003-4975/90/$3.50
496
HOW TO DO IT SPOTNITZ PACING IN CONGENITAL HEART DISEASE
Ann Thorac Surg 1990;49:495-6
Fig 1 . Positive-fixation, screw-in lead has polyurethane insulation, small cross-section, and a permanently extended fixation coil. Counterclockwise rotation minimizes "hang-ups" during insertion.
pacemaker generators currently available are satisfactory for subcutaneous sites, except in small infants. Redundant right atrial lead loops should allow for 5 to 10 years of growth in these patients (Gheissari A and Spotnitz HM, unpublished data). The techniques described have been used in 2 infants (aged 9 and 12 months) and 13 children (aged 3, 3, 5, 5, 5, 6, 6, 7, 7, 8, 9, 9, and 10 years) at the Columbia-Presbyterian Medical Center since October 1985 with no complications or need for reoperation. In adults, 342 endocardial screw-in leads have been used, with no ventricular lead displacement. The atrial lead displacement rate in adults has been 3%. No perfect method of long-term pacing has been demonstrated, and both exit block and lead displacement can be anticipated in the younger population as our experience increases. It
Fig 3 . Ventricular inhibited pacemaker inserted in a 6-year-old child ioith corrected transposition for sick sinus syndrome after closure of an atrial septa1 defect. The lead is placed high in the outflow tract of the right vcntricle to prevent diaphragmatic pacing, zohich zoas observed from locations closer to the apex. A generotis lead loop alloius for groicith. Lead loops mid outflow tract pacing are likely to result in lead displacement unless positiire fixation leads are used.
is hoped that this description will improve the results of transvenous pacing in this often challenging group of patients.
References
Fig 2 . Transvenous dual-chamber demand pacemaker inserted in October 1985 in a 3-year-old child for complete heart block after niitral valve replacement. The leads enter the heart through the left superior vena cava and the coronary sinus. Lead loops provide extra length to allow for groruth. A longer loop for the atrial lead zuould be preferable but u ~ a sprevented by the location of entry into the right atrium.
1. Lillehei CW, Sellers RD, Bonnabeau RC Jr, Elliot RS. Chronic postsurgical complete heart block: with particular reference to prognosis, management, and a new P-wave pacemaker. J Thorac Cardiovasc Surg 1963;46:43&56. 2. Walsh CA, McAlister HF, Andrews CA, Steeg CN, Eisenberg R, Furman S. Pacemaker implantation in children: a 21 year experience. PACE 1988;11:194O-4. 3. Belott PH. Implantation techniques: new developments. In: Barold S, Mugica J, eds. New perspectives in cardiac pacing. Mount Kisco, NY: Futura, 1988;255-77. 4. Ong LS, Barold S, Lederman M, et al. Cephalic vein guide wire technique for implantation of permanent pacemakers. Am Heart J 1987;114:753-6. 5. Littleford PO, Parsonnet V, Specor SD. Method for the rapid and atraumatic insertion of permanent endocardial pacemaker electrodes through the subclavian vein. Am J Cardiol 1979; 43:980-2. 6. Belott PH. A variation on the introducer technique for unlimited access to the subclavian vein. PACE 1981;4:43-8.
