Europace Advance Access originally published online on February 8, 2007
Europace 2007 9(3):192-193; doi:10.1093/europace/eum003
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CARDIAC PACING
Integrated home monitoring predicts lead failure in a pacemaker dependent 4-year-old girl
German Paediatric Heart Centre Sankt Augustin, Department for Cardiology, Arnold-Janssen-Str. 29, D-53757 Sankt Augustin, Germany
Manuscript submitted 7 September 2006. Accepted after revision 17 December 2006.
* Corresponding author. Tel: +49 2241 249 653; fax: +49 2241 249 652. E-mail address: p.zartner{at}asklepios.com
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Abstract |
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A 4-year-old girl with post-surgical complete atrioventricular block received an epicardial dual chamber pacemaker system. During further growth intermittent exit block occurred, first misinterpreted as neurological seizures. The epicardial lead was replaced using a transvenous approach, and a pacemaker with an integrated home monitoring facility was implanted. After her discharge, a rise in the pacing threshold automatically initiated an event message. On the basis of this information, the patient was called in and imminent dislodgement of the ventricular lead was diagnosed by x-ray. The lead was repositioned and was found stable over 1-year follow-up.
Key Words: Children, Congenital Heart Disease, Emergency, Exit block, Pacemaker, Home monitoring
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Introduction |
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In young patients with congenital heart disease, pacemaker dependent bradyarrhythmias are observed more frequently than in the adult population.1
,2 Due to the patient's growth, the leads may become too short and result in exit block, which may be misinterpreted or may cause severe clinical symptoms. In these patients, an online tracking tool might help to foresee problems and to find solutions before failure occurs. This is discussed using the example of the first child in whom a pacemaker with a home monitoring facility was implanted. |
Case report |
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A Ross operation carried out for a dysplastic aortic valve in a female newborn led to complete atrioventricular block (cAVB) and an epicardial pacemaker system was implanted. At the age of 4, sudden syncopal attacks were observed by the mother. A neurological work-up with EEG and sleep laboratory revealed no pathological findings. During the next pacemaker follow-up, 4 weeks after the first attack, intermittent exit block was found. The unstable ventricular lead was abandoned, and a new transvenous lead (Fineline 4469, Guidant, St Paul, MN, USA) was inserted. For the first time, a pacemaker with an integrated home monitoring facility (Philos II DR-T, Biotronik, Berlin, Germany) was implanted in a child. Automatic threshold testing (active capture control, ACC) was at first programmed hourly. The parents were guided through the usage of the home monitoring transmission system, a modified mobile phone (Cardio Messenger), and given practical experience during the inpatient stay. Four days after discharge, an event message was sent automatically by the implant, indicating that the threshold of the ventricular lead had increased more than 1 V/day (Figure 1). The patient was called in, and elevated ventricular threshold was confirmed. Follow-up x-ray (Figure 2) and fluoroscopy demonstrated an altered configuration of the ventricular lead, with a loop outside the left subclavian vein. Surgery later confirmed this finding. After repositioning of the lead, the home monitoring system reported good and stable values for all sampled data during follow-up of over 1 year. No further syncopal attacks occurred.
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1.0 V). The first alarm (MS/FU, first mode switching episode since last follow-up) was due to high heart rate, prompting temporary mode switch episodes. The mode switch limit was later adapted.
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Discussion |
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The misinterpretation of intermittent ventricular exit block as possible seizures in this young girl's history motivated the implantation of a pacemaker system with an integrated home monitoring facility. As described in an adult patient,3
the home monitoring system is able to send automatically early information on possible lead failure, by analysing lead impedance. In the Philos II DR-T, this function is represented by the ventricular threshold. This test is performed daily at programmable intervals and the last measured value is, among others, automatically transmitted by text message to an Internet server. In this patient, the atypical route of the transvenous lead between the abdominally placed pacemaker and the right ventricular lead tip had a fulcrum at the venous entrance point in the subclavian vein (Figure 2). Arm movement may have tended to retract the lead tip. The online information on the increasing ventricular threshold allowed repositioning of the affected lead, with an added reserve loop before the patient became symptomatic.
The paediatric population poses special problems for pacemaker follow-up in that growth may cause lead failure, as it produces traction on the lead. An online monitoring system may assist in the early diagnosis of dysfunction of the pacemaker system, especially in young children, who cannot express specific symptoms.
Despite the size of the generator (12 cm3), which is not ideal in small children, the implemented data transmission regime seems effective and adaptable to individual requirements.
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Conclusion |
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Children's growth and higher level of physical activity cause failure rates above those in adults and imply a need for lead or system revision.4
The integrated home monitoring system is an uncomplicated tool able to assist in pacemaker follow-up and may be particularly useful in young children. Besides its capacity to monitor atrial and ventricular tachyarrhythmias, it helps to anticipate lead failure before clinical symptoms occur. Implantation of a device with this facility is recommended in pacemaker-dependent children. |
References |
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[1] Smerup M, Hjertholm T, Johnsen SP, Pedersen AK, Hansen PS, Mortensen PT, et al. Pacemaker implantation after congenital heart surgery: risk and prognosis in a population-based follow-up study. Eur J Cardiothorac Surg 2005; 28: 61–8.
[2] Balmer C, Fasnacht M, Rahn M, Molinari L, Bauersfeld U. Long-term follow up of children with congenital complete atrioventricular block and the impact of pacemaker therapy. Europace 2002; 4: 345–9.
[3] Scholten MF, Thornton AS, Theuns DA, Res J, Jordaens LJ. Twiddler's syndrome detected by home monitoring device. Pacing Clin Electrophysiol 2004; 27: 1151–2.[CrossRef][Medline]
[4] Silvetti MS, Drago F, Grutter G, De SA, Di CV, Rava L. Twenty years of paediatric cardiac pacing: 515 pacemakers and 480 leads implanted in 292 patients. Europace 2006; 8: 530–6.
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