Implantation of cardiac pacemakers has been practiced for at least five decades with continuous developments of the hardware. The invention of dual chamber pacemakers has initiated a debate concerning its superiority over single chamber ventricular pacemakers. Throughout the world, surgeons have been using dual chambered permanent pacemakers with successful follow ups. However, Pakistan has not yet taken the advantage of such pacemaker devices till now. We report three cases that underwent a dual chamber permanent pacemaker implantation for the first time in children less than 8 kg with successful follow ups

Amanullah, Muhammad Muneer

Ashfaq, Awais

Atiq, Mehnaz

Khan, Mansoor Ahmed

eCommons@AKU

eCommons@AKUSection of Cardiothoracic Surgery Department of SurgeryApril 2011Dual chamber pacemaker implants--a newopportunity in Pakistan for children withcongenital and acquired complete heart blockAwais AshfaqAga Khan UniversityMansoor Ahmed KhanAga Khan UniversityMehnaz AtiqAga Khan UniversityMuhammad Muneer AmanullahAga Khan UniversityFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_cardiothoracicPart of the Anesthesiology Commons, Pediatrics Commons, and the Surgery CommonsRecommended CitationAshfaq, A., Khan, M., Atiq, M., Amanullah, M. (2011). Dual chamber pacemaker implants--a new opportunity in Pakistan for childrenwith congenital and acquired complete heart block. Journal of the Pakistan Medical Association, 61(4), 421-3.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_surg_cardiothoracic/12421 J Pak Med AssocAbstractImplantation of cardiac pacemakers has been practicedfor at least five decades with continuous developments of thehardware. The invention of dual chamber pacemakers hasinitiated a debate concerning its superiority over singlechamber ventricular pacemakers. Throughout the world,surgeons have been using dual chambered permanentpacemakers with successful follow ups. However, Pakistanhas not yet taken the advantage of such pacemaker devices tillnow. We report three cases that underwent a dual chamberpermanent pacemaker implantation for the first time inchildren less than 8 kg with successful follow ups. Keywords: Dual chamber pacemaker implants, Congenitalheart block, Permanent pacemakers.IntroductionSince the first implantation of a cardiac pacemaker ina human in 1958 at the Karolinsksa Institute, Sweden;technological advances have enhanced the sophistication ofcardiac pacemakers.1 However, till today, the choice ofpacemakers has not been based on the results of clinical trials.There is a continuous debate on ventricular or dualchamber pacemakers regarding its design and usage. Dualchamber pacing maintains atrioventricular synchrony and canbetter preserve normal physiologic function compared tosingle chamber ventricular pacemakers.2 However, dualchamber pacemakers are more expensive, complex toimplant, programme and follow up. Surgeons over the world have used dual chamberpacemakers with successful outcomes, but its use has notbeen implemented in Pakistan. We report three cases in whicha dual chamber permanent pacemaker was implantedsuccessfully for the first time in children less than 8kilograms weight.Case-1:A 15 month old baby boy weighing 6.5 kg wasadmitted electively for the Atrial switch (Senning's)procedure. The baby was cyanosed since birth and had ahistory of recurrent respiratory tract infections.Echocardiography revealed dextrocardia with situs inversus,transposition of great arteries, sub-pulmonary stenosis, septalhypertrophy, and a 4 mm Atrial Septal Defect (ASD). The baby was operated for physiological correction ofdextro-transposition of the great arteries with Senningprocedure. On coming off cardiopulmonary bypass he was incomplete heart block requiring temporary epicardial pacing. The patient was extubated on Day 2 but remained inheart block. Details given in Figure-1a & 1b. He was plannedfor placement of a dual chambered permanent pacemaker. Aright antero-lateral thoracotomy was performed through the5th inter-costal space to place the epicardial leads to the rightatrium and right ventricle. Through a transverse incision inright mid abdomen, a retro-rectus sheath pocket was createdto place the generator box. The pacemaker was set at 100beats per min, patient was extubated on the operation table,and shifted in stable condition to the ICU without inotropicsupport. Post-operative echocardiogram revealed normal LVand RV systolic function. The patient had an unremarkablepost-op hospital stay and was discharged a week afterplacement of PPM. Students’ CornerCase SeriesDual Chamber Pacemaker Implants — A new opportunity in Pakistan forchildren with congenital and acquired complete heart blockAwais Ashfaq,1 Mansoor Ahmed Khan,2 Mehnaz Atiq,3 Muhammad Muneer Amanullah4Medical Student,1 Department of Anaesthesia,2 Department of Pediatrics and Child Health,3Division of Cardiothoracic Surgery, Department of Surgery,4 Aga Khan University, Karachi.Figure-1a (Left): Normal electrical conduction system of the heart. 1b (Right):Complete Heart Block showing a total disconnection of Sino-atrial Node fromAtrioventricular Node.Case-2:Our second child was a 5 month old Down'sSyndrome boy weighing 4 kg with a complete Atrio-ventricular septal defect (CAVSD) presenting with heartfailure. He was admitted electively for CAVSD repair, beingreferred from Dubai.The baby underwent complete repair of CAVSD withtwo patch technique. On coming off cardiopulmonary bypasshe was in complete heart block requiring temporaryepicardial pacing. Postoperative echocardiogram showed noregurgitation of the AV valves. The patient was shifted to ICUin a stable condition on AV sequential pacing. Four days later,the baby developed intermittent sinus rhythm with heart rateof 50-60/min. This did not improve any further and the childremained in complete heart block. He was planned forimplantation of a dual chamber permanent pacemaker. The second surgery was done through a transverseincision in the left anterior upper quadrant. A pocket wascreated in the rectus sheath to place the pacemaker generatorbox. Through a right antero-lateral thoracotomy thepacemaker leads were attached to the right atrium andventricle. The procedure was uneventful and the child wasextubated on the operation table, and shifted to CICU with noinotropic support. The patient was discharged home after aweek. He is being followed by the primary physician inDubai and has remained well.Case-3:A 1 year old baby girl, weighing 8 kg, presented in theER with fever for three days, vomiting and fits for two days.She was diagnosed to have congenital complete heart block(CCHB) with Stokes Adams attacks. At the time ofpresentation the child was irritable, blood pressure of 100/50,heart rate of 60/min. Clinical examination was unremarkable.Her echo showed dilated left ventricle, with an ejectionfraction of 75%. Her electroencephalogram (EEG) wasnegative for any epileptic activity. As she was symptomatic from her slow heart rate weplanned for placement of a dual chamber permanentpacemaker. Through a right lateral position, a verticalincision (Figure-3) was made along the mid-axillary line inthe 4th intercostal space to enter into the pleural cavity toplace the epicardial leads to the right atrium and ventricle(Figure-2). The pacing box was positioned inferior to thescapula beneath the latissimus dorsi muscle. The axillaryincision scar gets well concealed under the upper arm. Inprepubescent female patients, it poses less potential forsubsequent breast tissue distortion. Post operatively, the childremained stable with the permanent pacemaker ratemaintained at 120-130/min. Her hospital stay wasVol. 61, No. 4, April 2011 422Figure-2: Endovascular Insertion technique of dual chamber pacemaker.Figure-3: Patient positioning and incision for a vertical mid axillary incisions. Thelattisimus dorsi muscle is retracted laterally and the serratus anterior muscle splitalong its muscle fibers to expose the chest wall.423 J Pak Med Assocunremarkable and she was discharged on the 4th postoperative day. She is regularly followed-up in the pacemakerclinic and she remains well with her PPM checks beingsatisfactory. DiscussionThe number of pacemakers implanted worldwidereached to over 600,000 in 2000.3 To date, clinicalrecommendations and guidelines regarding the selection ofpacing systems have been based on small clinical studies andretrospective analyses of existing databases.4The first randomized trial comparing ventricular withdual chamber pacing suggested that dual chamber pacingreduces the rate of death, stroke, and heart failure, particularlyamong patients with sinus-node dysfunction (SND).5Maintaining the normal sequence of atrial and ventricularactivation tends to optimize ventricular filling and cardiacoutput. The pacemaker syndrome, a constellation ofsymptoms associated with asynchronous atrial activationfrom ventricular pacing, may also be prevented by dual-chamber pacing. A reduction in stroke has also beendemonstrated.5 However, a report by the American College ofCardiology suggests the use of dual chamber pacemaker incases of SND and AV block where AV synchrony duringpacing is desired, or when there is a suspected abnormality ofAV conduction or increased risk of future AV block.6All the three cases reported by us encounteredcomplete heart block as a result of either SND or bundleinjury involving AV node which made them ideal candidatesfor dual chamber pacing. They had an unremarkable post-operative recovery and 4 month follow up in each case. Therewere no failed attempts in any of the reported cases. This isin contradiction to earlier studies that have reported a numberof complications involving cardiomyopathy and pacemakerinfections.7 A recent study reported dual chamber devices tobe independent predictors of infection with a rate of 0.5%when compared to single chambered devices.8 The study byCohen et al also reported trisomy 21 and pacemaker revisionsas significant risk factors in the development of infectionafter pacemaker implantation.7 Our second patient, a knowncase of Down's syndrome had an uneventful post-op followup with no indications for any worsening condition.The insertion techniques are variable and depend onthe surgeon's preference. Epicardial pacing is a common andeffective means of pacing in children9 and are preferred inchildren weighing less than 15 kilograms. It is alsorecommended for those with intra-cardiac shunts or thosehaving functionally univentricular anatomy. The use ofsteroid-eluting leads has led to further decrease in the rate ofcomplications associated with epicardial pacing. Other meansof insertion involve an Endo-cardial pacing that also has alower complication rate.10However, the issue of dual chamber cost-effectivenessremains to be addressed. The average cost per permanentpacemaker placement was approximately Pak Rupees294,251.00. As these are the first cases being reported, it isnot possible to generalize the cost or to calculate healthexpenditure to sustain this treatment for life. However it canbe predicted that these individuals may have to undergosecondary surgeries for battery replacement after a period of8-10 years. Otherwise, they are expected to lead a normal andhealthy life. Moreover, in our region this is the first time that a dualchamber pacemaker has been implanted and till today thereare only 3 cases. Therefore, the results reported by us cannotbe generalized but surely taken into account when such casesare managed. AcknowledgementWe thank the author, Awais Ashfaq, for contributingthe figures for the manuscript.References1. Elmqvist R, Senning A. Implantable pacemaker for the heart. In: Smyth CN, ed.Medical electronics: proceedings of the Second International Conference onMedical Electronics, Paris, June 24-27, 1959. London: Iliffe, 1960; 253-4.2. Lamas GA. Physiological consequences of normal atrioventricular conduction:applicability to modern cardiac pacing. J Card Surg 1989; 4: 89-98. 3. Lamas GA, Lee KL, Sweeney MO, Silverman R, Leon A, Yee R, et al.Ventricular pacing or dual-chamber pacing for sinus-node dysfunction. N EnglJ Med 2002; 346: 1854-62.4. Gregoratos G, Cheitlin MD, Conill A, Epstein AE, Fellows C, Ferguson TB Jr, etal. ACC/AHA guidelines for implantation of cardiac pacemakers andantiarrhythmia devices: a report of the American College ofCardiology/American Heart Association Task Force of Practice Guidelines(Committee on Pacemaker Implantation). J Am Coll Cardiol 1998; 31: 1175-209.5. Andersen HR, Thuesen L, Bagger JP, Vesterlund T, Thomsen PE. Prospectiverandomised trial of atrial versus ventricular pacing in sick-sinus syndrome.Lancet 1994; 344: 1523-8. 6. Gregoratos G, Cheitlin MD, Conill A, Epstein AE, Fellows C, Ferguson TB Jr,et al. ACC/AHA Guidelines for implantation of cardiac pacemakers andantiarrhythmia devices: Executive Summary A Report of the American Collegeof Cardiology/American Heart Association Task Force on practice guidelines(Committee on Pacemaker Implantation). Circulation 1998; 97: 1325-35.7. Cohen MI, Bush DM, Gaynor JW, Vetter VL, Tanel RE, Rhodes LA. Pediatricpacemaker infections: twenty years of experience. J Thorac Cardiovasc Surg2002; 124: 821-7.8. Nery PB, Fernandes R, Nair GM, Sumner GL, Ribas CS, Menon SM, et al.Device related infection among patients with pacemakers and implantabledefibrillators: incidence, risk factors, and consequences. J CardiovascElectrophysiol 2010; 21: 786-90.9. Walsh CA, McAlister HF, Andrews CA, Steeg CN, Eisenberg R, Furman S.Pacemaker implantation in children: a 21 year experience. Pacing ClinElectrophysiol 1988; 11: 1940-4.10. Cohen MI, Bush Dm, Vetter VL, Tanel RE, Wieand TS, Gaynor JW, et al.Permanent epicardial pacing in pediatric patients: seventeen years of experienceand 1200 outpatient visits. Circulation 2001; 103: 2585-90.

Dual chamber pacemaker implants--a new opportunity in Pakistan for children with congenital and acquired complete heart block

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Dual chamber pacemaker implants--a new opportunity in Pakistan for children with congenital and acquired complete heart block

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