Steroid-Eluting Epicardial Pacing Electrodes: Six Year Experience of Pacing Thresholds in a Growing Pediatric Population (original) (raw)
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Chronic Performance of a Transvenous Steroid Pacing Lead Used as an Epi-Intramyocardial Electrode
Pacing and Clinical Electrophysiology, 1998
KARPAWICH, P.P., ET AL.: Chronic Performance of a Transvenous Steroid Pacing Lead Used as an Epiintramyocardial Electrode. Excessive surface fibrosis or fat limits effective electrode insertion in patients requiring epicardial pacing. We present chronic performance of a modified transvenous steroid lead used as an epi-intramyocardiai electrode in a patient following repair of a univentricular heart after failure of both standard and steroid-eluting epicardial leads. Low implant threshold values remained stable during a 3-year postimplant interval demonstrating an effective and innovative approach to epicardial pacing. (PACE 1998; 21:1486-1488
Circulation, 2001
Background-The purpose of this study was to evaluate the long-term outcome of all pediatric epicardial pacing leads. Methods and Results-All epicardial leads and 1239 outpatient visits between January 1, 1983, and June 30, 2000, were retrospectively reviewed. Pacing and sensing thresholds were reviewed at implant, at 1 month, and at subsequent 6-month intervals. Lead failure was defined as the need for replacement or abandonment due to pacing or sensing problems, lead fracture, or phrenic/muscle stimulation. A total of 123 patients underwent 207 epicardial lead (60 atrial/147 ventricular, 40% steroid) implantations (median age at implant was 4.1 years [range 1 day to 21 years]). Congenital heart disease was present in 103 (84%) of the patients. Epicardial leads were followed for 29 months (range 1 to 207 months). The 1-, 2-, and 5-year lead survival was 96%, 90%, and 74%, respectively. Compared with conventional epicardial leads, both atrial and ventricular steroid leads had better stimulation thresholds 1 month after implantation; however, only ventricular steroid leads had improved chronic pacing thresholds (at 2 years: for steroid leads, 1.9 J [from 0.26 to 16 J]; for nonsteroid leads, 4.7 J [from 0.6 to 25 J]; PϽ0.01). Ventricular sensing was significantly better in steroid leads 1 month after lead implantation (at 2 years: for steroid leads, 8 mV [from 4 to 31 mV]; for nonsteroid leads, 4 mV [from 0.7 to 10 mV]; PϽ0.01). Neither congenital heart disease, lead implantation with a concomitant cardiac operation, age or weight at implantation, nor the chamber paced was predictive of lead failure. Conclusions-Steroid epicardial leads demonstrated relatively stable acute and chronic pacing and sensing thresholds. In this evaluation of Ͼ200 epicardial leads, lead survival was good, with steroid-eluting leads demonstrating results similar to those found with historical conventional endocardial leads. (Circulation. 2001;103:2585-2590.)
A Comparison of Steroid-Eluting Epicardial versus Transvenous Pacing Leads in Children
Journal of Cardiac Surgery, 2000
Objective: To evaluate the acute and chronic performance of steroid-eluting (SE) epicardial (EPI) pacing leads as compared t o SE transvenous (TV) pacing leads in children. Methods: From 1989 through 1997,55 children with congenital heart disease received a t o t a l of 85 SE pacing leads, of which 38 were EPI and 47 TV. The mean age of children receiving EPI leads was younger than those receiving TV leads (7.7 months vs 15.1 years, p = 0.0011, and they had shorter follow-up (17.2 months vs 36.2 months, p e 0.001). All leads were evaluated for acute and chronic sensing and capture thresholds, and impedance. Results: Acute and in particular chronic atrial and ventricular sensing and capture thresholds in SE EPI and TV leads were essentially equivalent.
Improved Chronic Epicardial Pacing in Children: Steroid Contribution to Porous Platinized Electrodes
Pacing and Clinical Electrophysiology, 1992
Porous Platinized Electrodes. Although new "low threshold" epicardial eiectrodes combine steroid tvith a porous, pJafinized-pJatinum surface, (he actuai contribution of steroid eJution has not been established. We evaluated this new electrode surface design with and without steroid in 13 children, ages 1-22 years. Both electrodes are unipolar and of similar surface area. The Medtronic Model 495'1-P is a barb design for epimyocardial insertioji without steroid while the Model 10295A is a steroid eJufing, epicardial diskshaped design. Both electrodes were implanted for atrial and ventricular pacing. At implant, sensed P and H waves, and pacing impedances were comparable between bolh electrodes. There were no signi/icanf di//erences between initial measured pulse width or calculated energy thresholds for the first 2 months following implant. Strength-duration curves for both electrodes at 1 month were comparable to implant values. After 2 months, the threshold of the nonsleroid electrode peaked and stabilized at a signi/icantiy higher fP < 0.05) level than the more constant steroid elut'mg electrode, This di//erence continued for the first year/oJlowing implant. We conclude that the new porous, platinized-platinum electrode design intrinsically limits initial electrode-tissue interface reactivity in children and improves epicardiaJ pacing with low chronic threshold values. Steroid elution augments these intrinsic qualities by maintaining fibrous capsule stability with more constant low thresholds over time. (PACE, Vol. 15, August 1992) children, epicardial pacing, steroid elution, porous-platinum Address for reprints: Peter P. Karpawich, M.D., Section of Cardiology, Children's Hospital of Michigan, 3901 Beauhien Blvd., Detroit. MI 48201. Fax; (313) 993-0894.
Twenty years experience with pediatric pacing: epicardial and transvenous stimulation
European Journal of Cardio-thoracic Surgery, 2000
Objective: Permanent cardiac pacing in children and adolescents is rare and often occurs by means of epicardial pacing. Based on two decades of experience, operative and postoperative data of patients with epicardial and transvenous pacing were analyzed retrospectively. Methods: Between October 1979 and December 1998, 71 patients (mean age, 5.3^4.2, range, 1 day±16.2 years; mean body weight, 181 2; range, 8±56 kg) underwent permanent pacemaker implantation. Indications were sinus node dysfunction and atrio-ventricular block following surgery for congenital heart disease (69%), or congenital atrioventricular block (31%). Pacing was purely atrial (1.4%), purely ventricular (73%), ventricular with atrial synchronization (5.6%), or atrioventricular synchronized (20%). Epicardial pacing was established in 49 (69%), transvenous in 22 (31%) patients. Follow-up was 3.4^3.8 years (epicardial) and 3.0^4.0 years (transvenous). Results: Epicardial leads were implanted in younger patients (mean age: 4.5 vs. 7.0 years, P , 0:05) and preferably after surgery induced atrioventricular block (78 vs. 46%, P , 0:05). The youngest patient with transvenous pacing was 1.3 years old (weight, 8.5 kg). At implantation epicardial ventricular stimulation threshold at 1.0 ms was 1.07^0.46 vs. 0.53^0.31 V (transvenous) (P , 0:05). The age-adjusted rate of lead-related reoperations was signi®cantly higher in patients with epicardial leads (P , 0:05), mainly due to increasing chronic stimulation thresholds resulting in early battery depletion. In three patients who received steroid-eluting epicardial leads initial low thresholds persisted after ®ve month to one years. In two patients with recurrent epicardial threshold increase, steroid-eluting epicardial leads led to good acute and chronic thresholds after nine to 15 month. Two post-operative death (2.8%) were probably due to a dysfunction of the (epicardial) pacing system. Conclusions: Transvenous pacing in the pediatric population is associated with a lower acute stimulation threshold and a lower rate of lead-related complications. If epicardial pacing is necessary (e.g. small body weight, special intracardiac anatomy (e.g. Fontan), impossible access to superior caval vein), steroid-eluting leads may be considered. q
Permanent Epicardial Pacing in Pediatric Patients
Circulation, 2001
Background-The purpose of this study was to evaluate the long-term outcome of all pediatric epicardial pacing leads. Methods and Results-All epicardial leads and 1239 outpatient visits between January 1, 1983, and June 30, 2000, were retrospectively reviewed. Pacing and sensing thresholds were reviewed at implant, at 1 month, and at subsequent 6-month intervals. Lead failure was defined as the need for replacement or abandonment due to pacing or sensing problems, lead fracture, or phrenic/muscle stimulation. A total of 123 patients underwent 207 epicardial lead (60 atrial/147 ventricular, 40% steroid) implantations (median age at implant was 4.1 years [range 1 day to 21 years]). Congenital heart disease was present in 103 (84%) of the patients. Epicardial leads were followed for 29 months (range 1 to 207 months). The 1-, 2-, and 5-year lead survival was 96%, 90%, and 74%, respectively. Compared with conventional epicardial leads, both atrial and ventricular steroid leads had better stimulation thresholds 1 month after implantation; however, only ventricular steroid leads had improved chronic pacing thresholds
The impact of steroid eluting leads on long term pacing in the atrium and ventricle
Journal of the American College of Cardiology, 1990
Steroid eluting leads introduced in 1983have been shown in a series of 51 atrial and 73 ventricular leads (Medtronic 4503and 4003)to offer no significant benefit in terms of sensing or pacing in either chamber at implant. All leads were tested non-invasively at follow-up using the patients' implanted generator (Pacesetter 283,285, Biotronik Diplos 04, OS, Medtronic 7005).In short term follow-up significantly larger P waves were seen 3.16 ± 2.16 vs 1.97 ± 0.97mV in comparisons made with presently available Medtronicstandard atrial leads. Both short and long term atrial thresholds were highly significantly improved 1.10 ± 0.55 vs 1.65 ± 0.94 V and 0.93 ± 0.09 vs 1.07 ± 0.28 V respectively. Short, medium and long term ventricular thresholds were also were significantly improved 0.90 ± OvsO.96 ± 0.13V, 0.91 ± 0.07vs 1.19 ± 0.47 V and 0.97 ± 0.2 vs 1.07 ± 0.29V. Existence of sinus node disease does not appear to influence atrial sensing in the short and medium term. In conclusion, the addition of steroid-elution to electrode design is an important advance in pacing technology and offers the possibility of safe long term pacing at 2.5 V output or even lower and permits maintenance of P wave detection in the short and medium term which is the period of greatest atrial sensing problems.
Initial Experience with 1.5‐mm2 High Impedance, Steroid‐luting Pacing Electrodes
Pacing and Clinical …, 1996
A 10%-15% decline in the mean telemetered atrial and ventricular pacing impedances was observed at 1 week, but thereafter remained stable. Acute pacing thresholds at 0.5 ms were 0.5 ± 0.3 V (atrial) and 0.4 ± 0.1 V (ventricular). Filtered P and R wave amplitudes were 3.7 ± 2.3 mV and 14.9 ± 5.9 mV, respectively. In 21 patients, no complications related to the atrial electrode were observed. Of 62 patients with ventricular electrodes, 4 patients (6%) experienced complications and required surgical intervention. On these, causative factors included micro-dislodgment (l patient), and perforation (l patient). Sudden unexplained exit block occurred late (> 6 weeks) in two patients. In the remainder of patients, pacing thresholds and sensed electrogram amplitudes remained stable throughout the 52-week follow-up period. Conclusions: The present stady validates that smaller surface (i.e., 1.5 mm~) steroidelating electrode designs offer excellent pacing and sensing performance with significantly higher pacing impedances. Although questions remain as to the cause of late exit block in two patients in this series, this relatively small surface electrode design offers promise toward achieving greater pacing efficiency and a theoretical 13%-16% (minimum) enhancement in permanent pacemaker longevity.