Congenital Heart Surgery without the Routine Placement of Temporary Pacing Wires

Steve Fishberger, Anthony Rossi, Juan Bolivar, Leo Lopez, Robert Hannan, Redmond Burke Congenital Heart Institute, Miami Children’s Hospital, Miami, FL USA

Abstract
• Objective: Temporary pacing wires have been associated with serious postoperative complications. Recommendations for the routine use of cardiac pacing wires after open hearts surgery are decades old and may not reflect current surgical outcomes. Methods: The electronic web-enabled records of all pts undergoing congenital heart surgery (CHS) from 1/1/02 through 12/31/05 were reviewed. Pts undergoing pacemaker implantation as a primary procedure or PDA ligation were excluded. Results: There were 1193 CHS performed (1041 with cardiopulmonary bypass). Median age was 167 days (range 0 days to 54 yrs), weight 6.1 kg (range 1-114 kg). Mortality to discharge was 2.5% and median postoperative stay was 7 days. No deaths were attributed to arrhythmias. There were temporary pacing wires placed 14 times (1.3%). Indications for placement of temporary wires included preoperative diagnosis of sinus node dysfunction (SND) in 4, intraoperative evidence of SND in 4, high degree AV block in 4 and atrial flutter control 2. Four of these pts (0.4%) eventually underwent permanent pacemaker implantation, 2 for persistent sinus node dysfunction and 2 for persistent high degree heart block. Implantation occurred at an average of 6 days after their primary procedure (range 1-12 days). Average postoperative stay of these pts was 21.8 days. Postoperative junctional ectopic tachycardia requiring therapy occurred in 10 pts (1%). All recovered without incident and none required pacing. Conclusions: Because of the diminished risks of unexpected postoperative arrhythmias in the current era, the routine placement of epicardial pacing wires may no longer be warranted. Meticulous surgery aimed at the preservation of the SAN, AVN and myocardial pump function alleviates the necessity for routine placement of temporary pacing wires after CHS. The need for temporary pacing wires can be predicted preoperatively or intraoperatively

Utilizing our web based medical record (i-Rounds, Teges), all progress notes of patients undergoing congenital heart surgery between February 2002 and November 2005 were queried for the following terms:

• • • • • • • •

Pacing Heart Block Arrhythmia Tachycardia Bradycardia JET Junctional rhythm AV Block

Patients Characteristics
• • • • • Total Procedures: 1193 (no PDAs) 319 neonates/433 infants Median age: 5.8 months Median weight: 6.2 kg Median postoperative stay 6 d

Background: Complications of temporary atrial and ventricular pacing wires placed at the end of a cardiac surgical procedure are numerous and well described. Complications during pacing may include phrenic nerve or diaphragmatic stimulation. The wires themselves may be proarrhythmic. Complications during removal may include bleeding, tamponade, arrhythmias or cardiac lacerations. The incidence of complications may be increased in anticoagulated patients
• Bolton JW, Mayer JE Jr. Unusual complication of temporary pacing wires in

children.
• • • •

Ann Thorac Surg. 1992 Oct;54(4):769-70 D. Dougenis. Perforation of the left ventricle by a temporary pacing lead. Intensive Care Medicine. 1990 Chung MK. Proarrhythmic effects of post-operative pacing intended to prevent atrial fibrillation: evidence from a clinical trial. Card Electrophysiol Rev. 2003 Jun;7(2):143-6 Preisman S, Cheng DC. Life-threatening ventricular dysrhythmias with inadvertent asynchronous temporary pacing after cardiac surgery. Anesthesiology.1999 Sep;91(3):880-3 Kanoh M, Ishikawa S, Suzuki M, et al. Postoperative infections related to pacing wires, pulmonary arterial catheters, and drainage tubes temporarily inserted during open-heart surgery] Jpn J Thorac Cardiovasc Surg. 1998 Feb;46(2):170-4

Results
• • • • 1193 operations 1041 open heart cases Hospital Mortality – 2.5% Median post operative length of stay -7days • Mortality attributed to arrhythmia - 0

Procedures Types
VSD TOF AVC Fontan DORV Truncus Norwood BiGlenn Other

At Risk Procedures for Postoperative Tachyarrhythmia or Heart Block

Procedure VSD repair TOF repair TOF/PA repair AVC repair Fontan DORV Truncus repair TGA/VSD repair IAA/VSD repair Ross/Konno Rastelli

Number of Cases 131 91 16 57 55 20 14 10 4 8 3

Postoperative Arrhythmias
• JET requiring treatment: 9 (0.8%) • Postoperative complete heart block 4 (0.3%) • Postoperative Sinus Node dysfunction requiring temporary pacing: 4 (0.3%) • Intra-operative atrial flutter: 2 (0.2%) • Post of atrial flutter: 2 (0.2%)

Indications for Temporary Pacing Wires (n=14, 1.2%)
• Preoperative history of Sinus Node dysfunction: 4 (0.3%) Postoperative Sinus Node dysfunction requiring temporary pacing: 4 (0.3%) AV block: 4 (0.3%) Intra-operative atrial flutter: 2 (0.2%)
5 number of pts 4 3 2 1 0 Preop PO SND AV SND Block Flutter

temp pacing permant pacin

• •

Permanent Pacing wires placed after primary procedure (n=4, 0.3%) • Persistent sinus node dysfunction:2 • Persistent complete heart block:2

Conclusions
• Diminished risk of postoperative arrhythmias in the current era is associated with attention to preservation of the sinus node, AV node and myocardial pump function during surgery. • The need for postoperative temporary pacing wires can be predicted preoperatively or intraoperatively. • Routine placement of epicardial pacing wires may no longer be warranted.

Summary
The selective approach to placement of temporary epicardial pacing wires following congenital cardiac surgery is an acceptable strategy in our institution due to the diminished incidence of postoperative arrhythmias, and the ability accurately to predict those patients who will benefit. In programs with highly experienced surgical and cardiac intensive care unit teams, the practice of routinely placing these wires on all patients who undergo congenital cardiac surgery may need to be reconsidered.

Congenital cardiac surgery without routine placement of wires for temporary pacing. Fishberger SB, Rossi AF, Bolivar JM, Lopez L, Hannan RL, Burke RP. Cardiol Young 2008;18:96-9

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