Long-term outcomes of cardiac pacing in adults with congenital heart disease
Hilary Bowman, B.S. and Jeremy P. Moore, M.D., M.S.
Objective: To determine differences in surgical versus transvenous cardiovascular implantable electronic devices (CIEDs) in adults with congenital heart disease
Background: The population of adults with congenital heart disease (CHD) is growing rapidly as a result of improved surgical outcomes.1 Brady- and tachyarrhythmias constitute major clinical problems for these patients, often requiring cardiac implantable electronic device (CIED) placement. Little is known about the long-term outcomes after CIED placement in this cohort.
Methods: A retrospective review of all patients >18 years with CHD who had a CIED implanted at the UCLA Medical Center was performed. Patients were grouped by method of system implantation: transvenous, surgical, or hybrid. The primary outcome was the need for premature system revision, and secondary outcomes included any system malfunction (e.g., lead failure) and acute or long-term complications, as defined by previous studies of CIEDs in the general population.2Additionally, lead performance characteristics such as energy thresholds, sensing, and impedance were evaluated over time. The acute period (first 6 weeks) was excluded from this latter analysis.
Results: A total of 93 CIEDs (61 transvenous, 29 surgical, 3 hybrid) were implanted in 82 patients (mean age 35.5, 42% male) with baseline data shown in Table 1. At baseline, the surgical CIED group was more often characterized by both single ventricle morphology and cyanosis. Surgical CIED patients were more likely to receive intra-pocket antibiotics, and to experience longer hospital stays post-procedure. There were no differences between groups in number of infections and acute or chronic complications. During follow up, there were 16 CIEDs failures requiring reintervention (11 transvenous, 4 surgical, and 1 hybrid). There was no difference in time to unplanned reintervention between groups (Figure 1). The total number of CIEDs that malfunctioned was 24 (14 transvenous, 9 surgical, and 1 hybrid). There was no difference in time to device malfunction (Figure 2). Lead performance data is summarized in Table 2. Surgical atrial leads but not ventricular leads were associated with higher energy thresholds as compared to transvenous leads. Ventricular pacing impedance increased over time in surgical versus transvenous leads, whereas there was no difference in atrial impedance between groups. Finally, atrial sensing worsened over time in the transvenous versus the surgical group, whereas no significant differences in ventricular sensing was noted.
Conclusion: In this initial analysis of a cohort of adults with CHD, we found no difference in time to system malfunction or reintervention between transvenous and surgical CIEDs, nor in acute or long-term complications. Lead characteristics were similar between groups, but in the surgical group, baseline atrial energy threshold was higher and ventricular lead impedance increased more quickly over time. Conversely, surgical leads showed relatively better atrial sensing over time compared to transvenous leads.
Limitations: This was a retrospective analysis and was thus limited by design. Some patients were transferred to our center following implantation, so that not all of their medical records were presently available to us, whereas other patients were lost to follow-up, limiting our ability to collect complete follow-up data.
- Warnes CA. The adult with congenital heart disease: born to be bad?. Journal of the American College of Cardiology. 2005 Jul 5;46(1):1-8.
- Cantillon DJ, Dukkipati SR, Ip JH, Exner DV, Niazi IK, Banker RS, Rashtian M, Plunkitt K, Tomassoni GF, Nabutovsky Y, Davis KJ. Comparative study of acute and mid-term complications with leadless and transvenous cardiac pacemakers. Heart rhythm. 2018 Jul 31;15(7):1023-30.