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Hemodynamically optimized temporary cardiac pacing after surgery for congenital heart defects
J Janousek1, P Vojtovic, V Chaloupecký
1Kardiocentrum, University Hospital Motol, Prague, Czech Republic. jan.janousek@lfmotol.cuni.cz
Insights
Optimized temporary dual chamber pacing improved hemodynamics in children after congenital heart surgery. This approach enhanced arterial pressures and reduced central venous pressures, benefiting patients with heart failure and dysrhythmias.
Area of Science:
- Pediatric Cardiology
- Cardiac Electrophysiology
- Cardiovascular Surgery
Background:
- Disturbances in atrioventricular (AV) synchrony and ventricular contraction can negatively impact hemodynamics, particularly in patients with compromised cardiac function.
- Postoperative dysrhythmias and low cardiac output are common challenges in children following congenital heart surgery.
Purpose of the Study:
- To evaluate the effectiveness of hemodynamically optimized temporary dual chamber pacing in improving hemodynamic parameters in pediatric patients after congenital heart surgery.
- To assess the impact of various optimized pacing modes on arterial and central venous pressures.
Main Methods:
- The study included 23 children (5 days to 7.7 years) with postoperative dysrhythmias and hemodynamic compromise.
- Four temporary dual chamber pacing modes were individually optimized to maximize systolic and mean arterial pressures.
- Hemodynamic parameters (systolic, mean arterial, and central venous pressures) were compared between optimized pacing and baseline or conventional pacing modes.
Main Results:
- Optimized pacing significantly increased mean arterial systolic pressure (71.5 to 80.5 mmHg, P < 0.001) and mean arterial pressure (52.3 to 59.7 mmHg, P < 0.001).
- Central venous (left atrial) pressure significantly decreased (12.3 to 11.0 mmHg, P < 0.001 for CVP; 10.5 to 9.2 mmHg, P < 0.005 for LAP).
- Various individually optimized pacing techniques successfully improved hemodynamics.
Conclusions:
- Individually optimized temporary dual chamber pacing is a viable strategy to improve AV synchrony and ventricular contraction in pediatric patients.
- This pacing approach effectively enhances hemodynamic stability in children with heart failure and selected dysrhythmias post-congenital heart surgery.
Abstract:
Disturbance of normal AV synchrony and dyssynchronous ventricular contraction may be deleterious in patients with otherwise compromised hemodynamics. This study evaluated the effect of hemodynamically optimized temporary dual chamber pacing in patients after surgery for congenital heart disease. Pacing was performed in 23 children aged 5 days to 7.7 years (median 7.3 months) with various postoperative dysrhythmias, low cardiac output, and/or high inotropic support and optimized to achieve the highest systolic and mean arterial pressures. The following four pacing modes were used: (1) AV synchronous or AV sequential pacing with individually optimized AV delay in 11 patients with first- to third-degree AV block; (2) AV sequential pacing using transesophageal atrial pacing in combination with a temporary DDD pacemaker for atrial tracking and ventricular pacing in three patients with third-degree AV block and junctional ectopic tachycardia, respectively, who had poor signal and exit block on atrial epicardial pacing wires; (3) R wave synchronized atrial pacing in eight patients with junctional ectopic tachycardia and impaired antegrade AV conduction precluding the use of atrial overdrive pacing; (4) Atrio-biventricular sequential pacing in two patients. Pressures measured during optimized pacing were compared to baseline values at underlying rhythm (13 patients with first-degree AV block or junctional ectopic tachycardia) or during pacing modes commonly used in the given clinical situation: AAI pacing (1 patient with slow junctional rhythm and first-degree AV block during atrial pacing), VVI pacing (2 patients with third-degree AV block and exit block and poor sensing on epicardial atrial pacing wires) and dual-chamber pacing with AV delays set to 100 ms (atrial tracking) or 150 ms (AV sequential pacing) in 7 patients with second- to third-degree AV block and functional atrial pacing wires. Optimized pacing led to a significant increase in arterial systolic (mean) pressure from 71.5 +/- 12.5 (52.3 +/- 9.0) to 80.5 +/- 12.2 (59.7 +/- 9.1) mmHg (P < 0.001 for both) and a decrease in central venous (left atrial) pressure from 12.3 +/- 3.4 (10.5 +/- 3.2) to 11.0 +/- 3.0 (9.2 +/- 2.7) mmHg (P < 0.001 and < 0.005, respectively). In conclusion, several techniques of individually optimized temporary dual chamber pacing leading to optimal AV synchrony and/or synchronous ventricular contraction were successfully used to improve hemodynamics in patients with heart failure and selected dysrhythmias after congenital heart surgery.