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Published on: July 18, 2014
Pacemaker implantation after congenital heart surgery: risk and prognosis in a population-based follow-up study
Morten Smerup1, Thomas Hjertholm, Søren P Johnsen
1Department of Cardiothoracic & Vascular Surgery T, Aarhus University Hospital, Skejby Sygehus, Brendstrupgaardsvej, 8200 Aarhus N, Denmark. morten.smerup@ki.au.dk
Insights
High RACHS score predicts mortality and pacemaker system failure in pediatric patients after congenital heart surgery. Early implantation and younger age at operation also increase risks, highlighting the need for improved risk stratification.
Area of Science:
- Pediatric Cardiology
- Cardiac Surgery
- Biomedical Engineering
Background:
- Congenital cardiac surgery can lead to heart block and sinus node dysfunction, historically associated with high morbidity.
- Advances in surgical techniques and pacemaker technology have reduced mortality, but pacemaker implantation in children still carries risks.
- Pacemaker system failure and replacement contribute significantly to morbidity in pediatric patients.
Purpose of the Study:
- To identify prognostic factors for mortality in pediatric patients requiring pacemakers post-cardiac surgery.
- To determine predictors for pacemaker system failure in this population.
- To analyze the impact of implantation timing on outcomes.
Main Methods:
- Historical prospective follow-up analysis of pediatric patients (<18 years) who received pacemakers between 1981-2002.
- Data sourced from the Danish Pacemaker Register and hospital records.
- Kaplan-Meier survival estimates and Cox proportional hazards analysis (Relative Risk) were employed to identify significant factors.
Main Results:
- High RACHS (Risk Adjustment for Congenital Heart Surgery) score, younger age at implantation, younger age at operation, and epicardial leads were significant predictors of early mortality.
- Similar factors (high RACHS score, younger age at implantation, younger age at operation, epicardial leads) predicted the failure of the first pacemaker system.
- High RACHS score demonstrated a 16.57-fold increased risk of mortality and a 4.84-fold increased risk of system failure.
Conclusions:
- The RACHS score is a significant predictor of both mortality and pacemaker system failure in pediatric patients post-cardiac surgery.
- This study is the first to establish a correlation between RACHS score and pacemaker system outcomes.
- Findings have implications for preoperative risk stratification and parental counseling for children with congenital heart disease requiring pacemakers.
Objective:
Although earlier a feared complication of congenital cardiac surgery, the incidence of heart-block and sinus node dysfunction has been lowered to 1-4% due to improved surgical techniques and better anatomical understanding of the cardiac conduction system. Development of feasible pacemaker technologies has further lowered mortality and morbidity. However, pacemaker implantation in paediatric patients is in itself associated with significant morbidity due to pacemaker system failure and replacement. The aim of the present study was to examine prognostic factors of mortality, failure of systems and timing of implantation after surgery in post-surgical pacemaker patients.
Methods:
We carried out a historical prospective follow-up analysis of all patients (age less than 18 years) who underwent pacemaker implantation due to post-surgical heart-block or sinus node dysfunction in the period 1981-2002 at our institution. Data was extracted from the Danish Pacemaker Register and hospital records. Kaplan-Meier survival time estimates and Cox proportional hazards analysis (Relative Risk, RR) were used to identify prognostic factors.
Results:
High RACHS score (RR, 16.57), low age at implantation (RR, 0.22), low age at operation (RR, 0.06) and epicardial lead (RR, 0.18) were significant predictors for early mortality. Similarly, high RACHS score (RR, 4.84), low age at implantation (RR, 0.32), low age operation (RR, 0.38) and epicardial lead (RR, 0.40) were significant predictors failure of 1st pacemaker system.
Conclusions:
We identified a number of prognostic factors of patient mortality and failure of systems. One factor, high RACHS score, was previously shown to predict mortality and length of ICU stay in paediatric cardiac surgery; however, this study is the first to show a correlation between RACHS score and mortality as well as failure of pacemaker systems. This may have future implications for preoperative risk stratification of patients and counselling of parents to patients with congenital heart disease.
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