Download Complications of Pacing System Infection

How to Handle Lead
Problems in Pediatric
& Congenital Heart
Disease
Alpay Celiker MD.
Acıbadem University
Department of Pediatric Cardiology
Istanbul
16 year old boy with
congenital AV block. VDD
pacemaker . No complaints
ECHO: Tricuspid valve
problem. Some signs of left
ventricular dysfunction
What to do???
Ways of Pacing
 Transvenous
 Epicardial
 Hybrid
Epicardial & Transvenous
Pacing
 Epicardial pacing

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Better for preserving venous system
Better results for long-term pacing
regarding pacing induced heart failure
Applicable for all conditions
More frequent lead problems
 Transvenous pacing system


Less lead problems
More problems on venous system
Complications of Pacing
System
Infection;
 Superficial,
 Lead
deep pocket
 Endocarditis
Lead malfunction
 Fracture
 Insulation
& other problems
Venous occlusion
Damage to cardiovascular system
Pacing System Infection
Localized or superficial infection
Localized pain, swelling
 Purulent discharge
Deep infection
 Fever
 Purulent discharge
 Pulmonary thromboembolism
 Recurrent pulmonary infection
 Sepsis

Pediatric Pacemaker
Infections*
•Perioperative Infections
•Staphylococcus species
(before discharge):
−Superficial 1,2 %
−Deep 0,2 %
were isolated in 44 %
•Increased Risks
−Reintervention
•Early Pacemaker
−Down
syndrome
−Subcutaneous 
preperitoneal pocket
Infections (< 60 days)
−Superficial 3,1 %
−Deep 1,2 %
•Late Pacemaker Infections
−Superficial
0,5 %
−Deep 0,7 %
* Cohen et al J Thorac Cardiovasc
Surg 2002; 124.
Treatment
 Localized Infection
Intravenous and oral antibiotics
 Local debridman
 Infrequently pacing system removal
 Deep Infection
 Pacing system removal
 Antibiotics



>2 weeks intravenously
 6 weeks total
Treatment Choices
•Intervention
− Small vegetations
− Strand formation
− Lead amenable to
extraction
•Surgery
−Large vegetations (>
10mm)
−Abcess formation
−Broken lead
−Abandoned old leads
−Concomitant surgery
need
Lead Malfunction
 Compromised pacing
 Failure to capture, high threshold
 Extra-cardiac stimulation
 Compromised sensing
 Under-oversensing
 Lead-lead interaction
 Electrical Abnormality
 Abnormal pacing impedance
 Abnormal high voltage impedance
 Low-amplitude electrogram
Signs of Lead Fracture
 No stimuli or stimuli without
capture
 Oversensing of false signals
 Permanent or intermittant high
lead impedance
Patient- and lead-related factors
affecting lead fracture in
children Olgun, Karagoz,
Celiker and Ceviz
Europace (2008) 10, 844–847
Structural Problems
Conductor failure
Insulation failure
Connector failure
Fixation failure
Methods to Determine
 Device interrogation
 ECG,
marker channel, impedance, event
recording
 Imaging
 X-ray,
fluroscopy
 Physical inspection or test at the
time of implant
Treatment of
Malfunctioning Lead
 Lead surgically abandoned or capped
 Lead electrically abandoned (mode
change)
 Lead explanted/repaired
 Device reprogrammed (polarity)
 Lead related intervention: reposition,
partially abandone
Factors to Consider When
Managing Leads
Patient
 Pacemaker
dependence
 Patient prognosis
 Risk of revision/replacement
procedure
Lead
 Malfunction
characteristics
 Adverse clinical consequencce
 Availability of reporogramming
Lead Extraction in
Children.
Why?
 Remove the intravascular and
intracardiac lead material
 Relieve and reconstruct the
venous access for the new leads
 Prevent lead related infection
Indications
 Class I:
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a: sepsis
b: life-threatening arrhythmia
c: life threatening condition
d: thromboembolic event caused by
retained lead
Obliteration of all useable veins
Lead interfereres with the operation of
another device
Procedure
 Basic lab tests and crossmatch for
blood should be obtained
 All x-rays related with pacemaker
and leads must be evaluated
 Arterial and venous catheters for
BP monitor and fluid supply
 Anesthesia
Lead Extraction
Methods
 Simple traction
 Snares
Needles eye, Goose neck
Lead locking devices
 Cook, Spectranetrics
Laser sheaths
Radiofrequency sheaths
Rotating sheaths
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Pulleys & Weights
Locking Stylets
Spectranetics Lead
Locking Device
Expanded
Compressed
Telescopic Sheaths
Laser Sheaths
Rotating Sheaths
Classification of
Complications
 Major Complication
Death
 Cardiac or vascular avulsion or tear
 Pulmonary embolism
 Stroke
 Minor Complication
 Pericardial effusion or hemothorax
 Vascular repair need
 Pneumothorax requiring a chest tube
 Pulmonary embolism not requiring surgical
intervention

Definition of Success
Complete Success - Removal of all
lead material from the vascular
space.
Partial Success - Removal of all but
a small portion of the lead.
Failure – Abandoning a significant
length of lead (more than 4cm)
Love CJ et al. PACE 2000; 23
Lead Problem n
Lead fracture
Upgrade
Infection
Dislodgement
Other reasons
14
8
7
5
5
Surgery for Lead Problems
 Infection
 Lead can not be explanted by
interventional methods
 Lead should not be explanted
by interventional methods
 Concomitant surgery need
New Problems !!!
 Coronary sinus leads
 ICD leads
 Lumenless electrodes
 Multipl leads
 Venous obstruction
 Tricuspid valve impingement
Conclusions
 Lead problems is frequent than in adult
population
 Although interventional methods have
been successfull, surgery may be
needed infrequently.
 Newer techniques may offer more
success and less complications.
 Technologic improvement at epicardial
and transvenous pacing may lower the
incidence of lead problems.