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Introduction
For years, endocardial pacing has been the technique of choice
for the adult population requiring a pacemaker. In the pediatric
pacing population, particularly in small children, there are
neither clear recommendations nor a consistent opinion
regarding the preferred implantation technique.1 Data from
adult pacing studies cannot be extrapolated to children
because permanent antibradycardia pacing in children is a
different entity than that in adults. This seemingly tendentious
assertion is supported by the essential differences in the
etiology of bradycardia, pacing indications, implantation
technique, and follow-up between children and adults.
The initial studies indicated that the epicardial approach is
better for children.2,3 This assertion was contested when
Address reprint requests and correspondence: Dr. Bratislav Kircanski,
Koste Todorovica 8, Clinical Center of Serbia, Belgrade 11000, Serbia.
E-mail address: braca032@yahoo.com.
1547-5271/$-see front matter B 2015 Heart Rhythm Society. All rights reserved.
Endocardial
pacing;
Methods
Study population
From May 1989 to December 2012, permanent antibradycardia pacemakers were implanted in 46 children weighing
http://dx.doi.org/10.1016/j.hrthm.2015.04.025
Implantation technique
All implantations were performed by a single surgeon (P.
Stojanov from the Referral Pacemaker Center) under general
endotracheal anesthesia in the operating room or catheterization laboratory. In the majority of cases, surgical loupe
magnifying glasses with 3 magnication were used during
the operations. Single- and dual-chamber pacemakers were
implanted in both sides but were predominately implanted in
the right side.
Since 2001, collection of preoperative ultrasonographic
measurements of the cephalic, subclavian, and axillary vein
diameters has been mandatory in our practice for children
younger than 3 years (we later applied this regulation to
children weighing r10 kg). These measurements allow for
selection of the optimal approach vein (ie, cephalic, external
jugular, or axillary vein), optimal pacing lead (based on the
consideration that the lead diameter should not exceed 50%
of the axillary or subclavian vein diameter), and, most
importantly, the appropriate surgical technique (ie, epicardial
or endocardial). The epicardial approach was used when the
diameter of the axillary or subclavian vein was o2.2 mm.
Our surgical technique proceeded as follows. A 3- to 4-cm
incision was made 12 cm infraclavicularly starting from
deltopectoral groove and extending medially and in parallel
to the clavicle. Next, a subcutaneous prepectoral pocket for
Figure 2 Directly xing the lead with resorptive sutures (without the use
of a sleeve).
Kircanski et al
Follow-up
Follow-up visits were 1 month after the implantation and every
6 months thereafter. All follow-up visits were performed by the
implanting surgeon and included pacemaker interrogation and
clinical examination to identify supercial cutaneous collateral
vein engorgement (ipsilateral to the implanted pacemaker),
which is sign of subclavian vein thrombosis.
Ultrasound examinations of the axillary and subclavian
veins were performed by a sonographer/angiologist from the
national referral clinic for vascular surgery. All of the
measurements were performed according to standard protocols, with the patient in the supine position and the patients
head turned slightly to the contralateral side. Images were
acquired from the longitudinal views of the far walls of veins
and analyzed from the proximal to distal ends to estimate the
ultrasonographic ndings of acute or chronic vein thrombosis. All studies were performed using a Siemens Acuson
Antares Ultrasound System (Siemens AG, Erlangen, Germany) using a linear array and 7- and 14-MHz scan heads.
Chest radiographs were obtained to monitor lead lengths
during growth once per year at the beginning of the study.
After we had gained experience, these radiographs were
obtained every second or third year.
Failure-free systems
A failure-free system was dened as a pacemaker system that
met the following criteria for the entire duration of followup: (1) no need for any type of surgical reintervention; (2)
stimulation threshold did not increase above 3 V at a pulse
width of 1.0 ms, and the amplitudes of the R and P waves
remained over 5 mV and 0.5 mV, respectively; and (3) no
signicant stenosis/obstruction in the venous system used for
lead insertion.
Statistical analysis
The descriptive statistics used for data presentation included
measures of the central tendency (mean), measures of
variability (range). and relative numbers. The statistical tools
of Microsoft Ofce Excel for Mac 1 (version 14.3) were used
for statistical analyses.
Results
The endocardial systems of 44 children, including 24
(54.5%) boys and 20 (45.5%) girls, were successfully
implanted. At implantation, mean weight, height, and age
were 6.24 kg (range 2.2510.40 kg), 66.7 cm (range 4886
cm), and 11.4 months (1 day47 months), respectively. All
implantations were performed within a period of 23.5 years.
The indications for pacing were isolated congenital complete
atrioventricular block in 23 children (52.2%) and postsurgical complete atrioventricular block in 21 children (47.8%;
latter occurred primarily after ventricular septal defect
corrections).
Single-chamber pacemakers were implanted in 42 children (95.5%) and dual-chamber pacemakers in 2 children
(4.5%; in both cases, the implantation was performed
because of complete atrioventricular block after surgical
correction of tetralogy of Fallot defects). All of the ventricular leads were standard length, passive xation, and
steroid eluting. Forty-three of the leads (97.8%) were
unipolar, and 1 (2.2%) was bipolar. Both of the atrial leads
of the dual-chamber systems were active and standard
length; 1 was bipolar, and the other 1 was unipolar. The
unipolar leads had lead body diameters of 1.2 mm (3.6Fr)
and 1.7 mm (5.1Fr). The bipolar lead body diameter was 2.2
mm (6.6Fr). In 40 children (90.1%), the ventricular leads
were implanted using the cephalic vein cutdown technique.
In 4 of the children (9.9%), the ventricular leads were
implanted after right external jugular vein preparation. The
reasons for the selection of the external jugular vein were
sharp angulation of the conuence of the internal jugular
vein and the subclavian vein that guided the lead cranially in
the rst child; partial thrombosis of the cephalic vein in the
second child; and small diameters of the cephalic veins in
the last 2 children (1.2 and 1.4 mm at the conuence with the
subclavian vein). In the children with a dual-chamber pacemaker, the accessing veins that were for the atrial leads were
the right axillary vein (puncture technique) in 1 child and the
right external jugular vein in the other. In 30 children
(68.1%), the diameters of the cephalic, axillary, and subclavian veins, as measured in millimeters by ultrasound
before implantation, were 1.98 (range 13.5), 3.43 (range 2
6.6), and 3.56 (range 2.27.5), respectively.
Postoperative clinical examinations were performed in 40
children (90.1%) to identify signs of subclavian vein
thrombosis. No supercial cutaneous collateral vein
engorgement ipsilateral to the implanted pacemaker was
observed in any of these children. Postoperative ultrasound
examinations of the axillary and subclavian veins were
performed in all of these children. In 5 of these patients
Figure 3
Thickening of the subclavian vein wall at the level of the implanted lead (arrow). SA subclavian artery.
8 patients underwent 2 replacements, and 2 patients underwent 3 replacements. The initial implantation was performed in the period from 2005 to 2012 in 24 patients.
In 6 patients (age 715 years), the system was upgraded to
dual-chamber at the time of elective battery replacement.
All atrial leads were easily placed after axillary vein
puncturing without complications or the need for phlebography. Moreover, there was no need for lead length adjustment because of the absorbable sutures that were used in the
initial xations.
The average stimulation threshold for the ventricular lead
was 1.37 0.34 V, the average R wave was 9.71 3.05
mV, and average ventricular lead impedance was 471 46
. Average battery longevity was 6.8 1.9 years.
During the entire follow-up period, no complications
(pocket hematomas or decubitus, pacemaker infection, lead
dislodgment, or exit block) were noted, except for 1 lead
fracture near the connector, which was detected 37 months
after implantation. This complication was successfully
resolved using a lead repair kit.
In 41 of the total of 42 children (97.6%), the system
remained failure-free during the follow-up period.
Patient
no.
Age at implantation
(months)
Weight at
implantation (kg)
Implanted lead
(manufacturer,
model)
Lead body
diameter (mm)
Follow-up period to
detected stenosis
(months)
Total
stenosis
degree (%)
1
2
3
4
5
9
14
6
9
4
7.95
4.80
3.40
6.40
5.16
Medtronic,
Medtronic,
Medtronic,
Medtronic,
Medtronic,
1.7
1.2
1.2
1.2
1.2
90
14
6
9
4
20
20
30
30
30
5023
4023
4033
4033
4073
Kircanski et al
Discussion
Only 1% of patients who underwent pacemaker implantation
are younger than 20 years.9 The subgroup of the pediatric
pacing population weighing r10 kg is even smaller. A
review of the literature revealed that permanent endocardial
pacing in patients weighing r10 kg has been applied to 82
patients (in publications that explicitly mention patients
body weights and implantation techniques).1014 Our series
of 44 patients weighing r10 kg who underwent endocardial
lead implantation with the cephalic (or external jugular) vein
cutdown technique currently represents the largest single
series. This series is distinguished by the low number of
complications (ie, system failure rate of 2.7%) over the long
follow-up period (mean 8.9 years). This series includes our
overall experience with the cephalic vein cutdown technique,
which we have been implementing in even the smallest
children for more than 23 years.15,16
The dilemma regarding use of the epicardial vs the
endocardial approach for pacing in children is old7 but
remains current and challenging,8 especially with regard to
young children. To the best of our knowledge, no randomized
study comparing the epicardial and endocardial approaches
has yet been published. Similarly, no single randomized or
nonrandomized pediatric study has been published regarding a
less frequently mentioned but no less important topicthe
comparison of implantation techniques for endocardial pacing
(eg, subclavian vein puncture vs cephalic vein cutdown).
In 1 study, reoperations were not needed in 80% of
children who had undergone epicardial pacing after 6 years
of follow-up.17 However, much worse results have been
reported (eg, 44% of patients requiring reintervention with
median follow-up of 6.4 years18 and epicardial lead dysfunction in 40.5% of patients after 3.5 3 years of followup12). The unfavorable aspects of the epicardial approach are
as follows: (1) this intervention is more invasive (ie, it
includes sternotomy or thoracotomy); (2) epicardial lead
fractures are more frequent than endocardial lead fractures
(because of greater mechanical stress)2; and (3) there are
higher stimulation thresholds4,12 and decreased battery
longevities compared with endocardial systems. The benets
of the epicardial approach when vein anomalies, thromboses,
or occlusions are present cannot be denied. Epicardial pacing
might also be preferable in children with certain congenital
heart defects19 or when right-to-left shunts are present
(because of risk of systemic embolization). As a rst argument in favor of epicardial access, many investigators have
highlighted the fact that venous access is preserved for
possible later endocardial implantation. They argued that,
with the epicardial approach, the risks of venous thrombosis
and occlusion are avoided.19,20 In our opinion, despite the
downsides of epicardial pacing, this technique is nearly
always feasible and might be used as a backup technique.
The predominance of the endocardial over the epicardial
approach in pediatric pacing has been recognized for years,20
but the endocardial approach became widespread in the
youngest pacing population after several cases of successful
endocardial implantations in newborns were reported.15
Figure 4
Chest radiographies taken immediately after implantation (A) and after 20 years (B).
Study limitations
A limitation of this study was that it was a single-center
retrospective study without a puncture technique control group.
Conclusion
This long-term follow-up study revealed that cephalic vein
cutdown for endocardial lead implantation in children
weighing r10 kg is a successful technique. Based on
personal experience with both epicardial and endocardial
pacing in children weighing r10 kg, our opinion is that the
endocardial approach is more demanding from the surgical
perspective because of the delicate anatomic structures. Our
personal negative experiences, which have been conrmed
in other studies30,31 with the puncture technique, motivated
Kircanski et al
References
1. Brignole M, Auricchio A, Baron-Esquivias G, et al. 2013 ESC guidelines on
cardiac pacing and cardiac resynchronization therapy: the task force on cardiac
pacing and resynchronization therapy of the European Society of Cardiology
(ESC). Developed in collaboration with the European Heart Rhythm Association
(EHRA). Europace 2013;15:10701118.
2. Sachweh JS, Vazquez-Jimenez JF, Schndube FA, Deabritz SH, Dorge H, Muhler
EG, Messmer BJ. Twenty years experience with pediatric pacing: epicardial and
transvenous stimulation. Eur J Cardiothorac Surg 2000;17:455461.
3. Udink CF, Breur J, Boramanand N, Crosson J, Friedman A, Brenner J, Meijboom
E, Sreeram N. Endocardial and epicardial steroid lead pacing in the neonatal and
paediatric age group. Heart 2002;88:392396.
4. Silvetti MS, Drago F, Grutter G, De Santis A, Di Ciommo V, Rava L. Twenty
years of cardiac pacing in paediatric age: 515 pacemakers and 480 leads
implanted in 292 patients. Europace 2006;8:530536.
5. Molina JE, Dunnigan AC, Crosson JE. Implantation of transvenous pacemakers
in infants and small children. Ann Thorac Surg 1995;59:689694.
6. Kammeraad JA, Rosenthal E, Bostock J, Rogers J, Sreeram N. Endocardial
pacemaker implantation in infants weighing r 10 kilograms. Pacing Clin
Electrophysiol 2004;27:14661474.
7. Beaufort-Krol GCM, Mulder H, Nagelkerke D, Waterbolk TW. Bink-Boelkens
MTE. Comparison of longevity, pacing, and sensing characteristics of steroideluting epicardial versus conventional endocardial pacing leads in children. J
Thorac Cardiovasc Surg 1999;117:523528.
8. Silvetti MS, Drago F, Di Carlo D, Placidi S, Brancaccio G, Carotti A. Cardiac
pacing in paediatric patients with congenital heart defects: transvenous or
epicardial? Europace 2013;15:12801286.
9. Bink-Boelkens MTHE: Cardiac pacing in infants and children. Neth J Cardiol
1992;5:199202.
10. Till JA, Jones S, Rowland E, Shinebourne EA, Ward DE. Endocardial pacing in
infants and children 15 kilograms or less in weight: medium term follow-up.
Pacing Clin Electrophysiol 1990;13:13851392.
11. Epstein ML, Knauf DG, Alexander JA. Long-term follow-up of transvenous
cardiac pacing in children. Am J Cardiol 1986;57:889890.
12. Silvetti MS, Drago F, De Santis A, Grutter G, Rava L, Monti L, Fruhwirth R.
Single-centre experience on endocardial and epicardial pacemaker system
function in neonates and infants. Europace 2007;9:426431.
13. Rosenthal E, Bostock J. Use of an atrial loop to extend the duration of endocardial
pacing in a neonate. Pacing Clin Electrophysiol 1997;20:24892491.
14. Robledo-Nolasco R, Ortiz-Avalos M, Rodriguez-Diez G, Jimenez-Carrillo C,
Ramirez-Machuca J, De Haro S, Castro-Villacorta H. Transvenous pacing in children
weighing less than 10 kilograms. Pacing Clin Electrophysiol 2009;32:S177S181.
CLINICAL PERSPECTIVES
This is the largest single series of patients weighing less 10 kg who have undergone endocardial pacemaker lead
implantation using the cephalic vein cutdown technique. The low incidence of complications observed during long-term
follow-up conrm that this technique, which is widely accepted and considered to be the technique of choice for adults, is
also feasible for this specic group of patients. Complications related to subclavian vein puncture (eg, pneumothorax,
hematothorax, brachial plexus lesions, arterial lesions) can be avoided, as can the signicant trauma related to the
thoracotomy required by the epicardial approach. Teams that include an experienced vascular surgeon, an angiologist, and a
pacemaker expert could implement this technique and improve the prognosis of this group of small patents who typically
require pacemaker therapy for their entire lifetimes.