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Vol. 71. Issue 1.
Pages 48-51 (January 2018)
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Vol. 71. Issue 1.
Pages 48-51 (January 2018)
Scientific letter
DOI: 10.1016/j.rec.2017.02.036
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Endocardial Pacing in Infants and Young Children Weighing Less Than 10 Kilograms
Estimulación endocárdica de niños con peso inferior a 10 kilogramos
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Aldo Campos-Quintero, José Antonio García-Montes, Rubén Cruz-Arias, Carlos Zabal-Cerdeira, Juan Calderón-Colmenero, Juan Pablo Sandoval
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Departamento de Cardiología Pediátrica y Hemodinámica e Intervención en Cardiopatías Congénitas, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
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Table. Clinical and Electrical Characteristics of Permanent Endocardial Pacemaker Implantation in Young Children
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To the Editor,

Permanent pacemaker implantation is a challenge in pediatric patients, who account for less than 1% of all patients who undergo this procedure.1 Widespread pacemaker use in children is limited by the absence of devices tailored to this population. Epicardial pacemaker placement used to be the preferred option for young patients, as the size of generators and endocardial leads were considered to be inappropriate and even dangerous for young children. Today, however, endocardial pacemakers are being increasingly used in the pediatric population as they offer several advantages, such as lower sensing and pacing thresholds and a reduced risk of lead fractures.2

We report our experience with permanent pacemaker implantation in patients weighing less than 10 kg at our hospital between January 2006 and March 2015. The procedure was performed in 25 patients with a median age of 17 months (range, 6-40 months) and a median weight of 7kg (range, 4.4-10.0 kg). The indication for pacing in 22 (88%) of the patients was complete atrioventricular block (AVB) after surgery (Table). The AVB had occurred after closure of a ventricular septal defect in all cases except one. The median time between surgery and implantation was 23 days (range, 9-40 days). The pacing leads were inserted by puncturing the right (n=15) or left (n=10) subclavian vein. The atrial or ventricular leads, measuring 52 cm in length and 2 mm in diameter, were inserted through 7-Fr introducer sheaths. Bipolar active-fixation leads were used in all cases. For dual chamber pacemakers, a right atrial loop measuring approximately 4 to 6 cm in length was created (Figure). Details of the generator models, implantation sites, pacing mode, and electrical parameters during implantation and follow-up are given in the Table. The generator was placed in a subpectoral pocket. The implantation procedure was completed without complications in most of the patients. One patient developed supraventricular tachycardia without repercussions during fixation of the atrial leads. In another patient, the atrial lead needed to be replaced due to malfunction caused by dislodgement on day 2 after the procedure. Twenty-two of the patients (88%) were followed up for a median of 48 months (range, 1-102 months). Generator replacement due to battery depletion was necessary in 2 children and there was no evidence of venous thrombosis during replacement in either case. Leads were extracted due to pocket-site infection in 3 patients (12%) at 8, 25, and 27 months. There had been no evidence of hematoma at the implantation site in any of the cases. Once the infection had cleared, the lead was removed using an epicardial surgical approach and replaced in 2 patients and was repositioned percutaneously on the contralateral side in the third. All the patients, including those who required lead extraction, were in good clinical health.

Table.

Clinical and Electrical Characteristics of Permanent Endocardial Pacemaker Implantation in Young Children

Patient  Congenital heart disease  Generator  Implantation sitePacing mode  Electrical parameters during implantation
      Atrium  Ventricle    AtriumVentricleHeart rate, max/min (bpm) 
            Sensitivity (mV)  Pacing treshold (mV)  Impedance (Ω)  Sensitivity (mV)  Pacing threshold (mV)  Impedance (Ω)   
ASD+ VSD  St JudeMicrony II  ------  Apex  VVIR  -------  -------  -------  N/A  N/A  N/A  185/90 
CoAo + PDA + VSD  Guidant InsigniaI Entra  Posterior wall  Apex  DDDR  N/A  N/A  464  N/A  N/A  512  150/80 
Double discordance + VSD  Vitatron  Posterior wall  Apex of LV  DDD  N/A  0.2  450  N/A  0.4  598  170/90 
AVC defect  St. JudeMicrony II  -----  RVOT  VVIR  -------  -------  ------  N/A  N/A  415  185/90 
VSD + PDA  Guidant InsigniaI Entra  Atrial appendage  RVOT  DDDR  N/A  N/A  610  N/A  N/A  530  180/80 
Supracardiac-type TAPVC in SVC  Guidant InsigniaI Entra  Posterior wall  Apex  DDD  3.5  0.4  420  3.5  0.4  430  180/90 
Dextrocardia, situs inversus, DORV  Guidant InsigniaI Entra  Posterior wall  Apex  DDD  0.75  0.6  447  8.6  0.9  464  150/90 
Structurally healthy heart  Guidant InsigniaI Entra  Posterior wall  Apex  DDDR  1.5    530  8.0    490  185/90 
TGA + VSD + subpulmonary ring  Guidant InsigniaI Entra  Lateral wall  Apex  DDDR  2.0  1.0  400  10  1.25  700  185/110 
10  VSD + PDA  Medtronic  Atrial appendage  RVOT  DDDR  0.19  2.4  866  15  2.1  952  180/80 
11  VSD + PDA  Boston ScientificAltrua  Atrial appendage  RVOT  DDD  1.0  0.75  470  6.0  0.5  440  185/70 
12  Structurally healthy heart + paralysis of right atrium  Boston ScientificAltrua  Posterior wall  RVOT  DDDR  N/A  N/A  420  8.5  N/A  480  185/90 
13  VSD + PDA  Boston ScientificAltrua  Atrial appendage  RVOT  DDDR  2.0  1.6  610  15  1.2  530  180/70 
14  VSD + PDA  Boston ScientificAltrua  Posterior wall  RVOT  DDDR  3.6  1.5  636  20.7  0.9  870  185/100 
15  Juxtaposed atrial appendages  Medtronic  Interatrial septum  Apex  DDD  1.0  0.6  764  6.8  1.1  697  185/100 
16  VSD + PDA  Boston ScientificAltrua  Atrial appendage  RVOT  DDDR  1.5  0.9  430  2.5  0.5  480  180/80 
17  AVC defect  Boston ScientificAltrua  Lateral wall  RVOT  DDDR  1.2  0.5  780  7.0  0.8  640  185/100 
18  ASD + VSD  Boston ScientificAltrua  Posterior wall  RVOT  DDDR  1.2  0.4  560  6.0  0.7  538  185/70 
19  VSD  Boston ScientificAltrua  Roof  Apex  DDDR  0.75  0.8  413  2.5  0.4  445  180/80 
20  VSD + PDA  Boston ScientificAltrua  Lateral wall  Apex  DDDR  0.75  1.2  534  2.5  1.2  568  180/80 
21  Intracardiac-type TAPVC in coronary sinus + VSD  Boston ScientificAltrua  Atrial appendage  RVOT  DDDR  0.5  0.9  474  2.5  0.5  540  185/90 
22  DORV  Boston ScientificAltrua  Roof  RVOT  DDDR  0.8  1.3  568  3.0  1.4  620  185/70 
23  CoAo + VSD  Boston ScientificIngenio MRI  Atrial appendage  RVOT  DDDR  1.0  1.5  610  6.5  0.7  740  185/100 
24  VSD  Boston ScientificIngenio MRI  Atrial appendage  RVOT  DDDR  0.75  0.6  468  2.5  0.8  534  185/90 
25  ASD + DORV  Boston ScientificIngenio MRI  Atrial appendage  RVOT  DDDR  0.75  0.4  788  2.5  0.4  753  185/110 
Patient  Electrical parameters during follow-up
  AtriumVentriclePacing %AV interval
  Sensitivity (mV)  Pacing threshold (mV)  Impedance (Ω)  Sensitivity (mV)  Pacing threshold (mV)  Impedance (Ω)  Atrial  Ventricular  SAV  PAV 
-----  -----  -----  N/A  N/A  N/A  NF  NF  NF  NF 
N/A  N/A  N/A  N/A  N/A  N/A  NF  NF  NF  NF 
1.75  2.5  650  N/A  0.75  450  29  99  NA  NA 
-----  -----  -----  N/A  N/A  N/A  -----  NA  -----  ----- 
1.2  3.25  310  8.6  5.0  380  100  NA  NA 
N/A  N/A  N/A  N/A  N/A  N/A  NF  NF  NF  NF 
2.0  0.1  470  N/A  2.5  500  57  100  NA  NA 
4.2  1.75  470  N/A  1.5  520  100  150  80 
N/A  N/A  N/A  N/A  N/A  N/A  13  98  NA  NA 
10  4.0  1.75  460  7.7  5.1  383  21  100  80  140 
11  2.0  0.05  370  N/A  0.05  410  100  NA  NA 
12  2.5  1.16  490  4.4  4.1  490  100  73  NA  NA 
13  0.75  0.75  460  N/A  2.5  420  99  NA  NA 
14  N/A  2.0  410  N/A  1.75  520  97  100  NA  150 
15  1.4  1.25  522  N/A  1.25  470  100  120  150 
16  2.4  1.24  610  N/A  1.25  480  100  NA  NA 
17  2.2  1.75  420  N/A  1.5  420  19  100  NA  NA 
18  0.5  1.5  420  N/A  1.5  420  14  100  NA  NA 
19  N/A  2.0  380  N/A  1.75  410  100  NA  NA 
20  1.0  1.25  530  N/A  1.75  430  40  100  NA  NA 
21  0.32  8.75  560  6.5  1.5  440  14  92  NA  NA 
22  2.4  1.25  410  N/A  1.25  460  57  100  NA  NA 
23  1.9  1.25  400  N/A  1.5  460  11  100  NA  NA 
24  0.9  6.25  N/A  12  2.0  N/A  NA  NA 
25  N/A  N/A  N/A  N/A  N/A  N/A  56  100  80  160 

ASD, atrial septal defect; AVC, atrioventricular canal; bpm, beats per minute; CoAo, coarctation of the aorta; DORV, doublet outlet right ventricle; LV, left ventricle; N/A, not applicable; NA, not available; NF, not followed up; PAV, paced AV; SAV, sensed AV; PDA, patent ductus arteriosus; RVOT, right ventricular outflow tract; SVC, superior vena cava; TAPVC, total anomalous pulmonary venous connection; TGA, transposition of the great arteries; VSD, ventricular septal defect.

Figure.

Two-year-old patient weighing 9kg with congenital atrioventricular block. Note the position of the leads in both the atrium and at the right ventricle apex (A). The same patient aged 8 years old and weighing 25kg (B). Note the minimum displacement of the leads despite the significant somatic growth.

(0.1MB).

A number of factors need to be considered when placing an endocardial pacemaker in young children. Lead displacement caused by growth can interfere with pacing, requiring the insertion of new leads within a relatively short period. Use of a longer atrial lead can prevent this from happening. Gheissari et al.3 calculated that a right loop of 8cm would allow a child to grow for 6 to 12 years without the need for reoperation and that approximately 10mm of lead per year should accommodate for somatic growth. Other authors, however, have warned that a surplus lead of this length could be displaced into the right ventricular outflow tract, possibly causing lung failure.4 In our experience, a loop length of approximately 4 to 6cm is adequate. We have detected no problems to date, although we acknowledge that larger series and longer follow-up times are necessary. Another important issue with pacemaker placement in young children is the thinness of the subcutaneous tissue layer, as the generator tends to exert tension against the tissue and can cause lesions. This increases the risk of infection and the need for extraction, as has been previously indicated.5 The use of subpectoral pockets has been associated with a lower risk of infection in such cases.6 Subpectoral placement is preferred not only for cosmetic reasons but also because of the greater protection provided by the pectoral muscle in young patients.

In conclusion, although patients require close lifetime follow-up due to the risk of venous thrombosis and the possible need for lead extraction, we consider that endocardial pacing in pediatric patients weighing less than 10kg is a reasonably safe and effective option in hospitals with experience.

References
[1]
K.A. McLeod.
Cardiac pacing in infants and children.
Heart., 96 (2010), pp. 1502-1508
[2]
E. Welisch, E. Cherlet, E. Crespo-Martínez, et al.
A single institution experience with pacemaker implantation in a pediatric population over 25 Years.
Pacing Clin Electrophysiol., 33 (2010), pp. 1112-1118
[3]
A. Gheissari, A. Hordof, H. Spotnitz.
Transvenous pacemaker in children: relation of lead lengthtoanticipatedgrowth.
Ann Thorac Surg., 52 (1991), pp. 118-121
[4]
H. Antretter, J. Colvin, U. Schweigmann, et al.
Special problems of pacing in children.
Indian Pacing Electrophysiol J., 3 (2003), pp. 23-33
[5]
R. Robledo-Nolasco, M. Ortiz-Avalos, G. Rodríguez-Diez, et al.
Transvenous pacing in children weighingless than 10 kilograms.
Pacing Clin Electrophysiol., 32 (2009), pp. 177-181
[6]
L. Baddour, A. Epstein, C. Erickson, et al.
Update on cardiovascular implantable electronic device infections and the management: a scientific statement from the American Heart Association.
Circulation., 121 (2010), pp. 458-477
Copyright © 2016. Sociedad Española de Cardiología
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