Long term complications in single and dual chamber pacing are influenced by surgical experience and patient morbidity

Abstract

Objective: To determine how short and long term complication rates after pacemaker implantation are influenced by patient morbidity, operator experience, and choice of pacing system.

Design: Retrospective analysis of 1884 patients who received VVI (n = 610), VDD (n = 371), or DDD devices (n = 903) between 1990 and 2001. Follow up period was 64 (34) months. The influence of age, sex, coronary artery disease, myocardial infarction, reduced left ventricular (LV) function, right ventricular (RV) dilatation, atrial fibrillation, device type, and operator experience on operation time and complication rate were analysed.

Results: Operation time was prolonged in patients with coronary artery disease, inferior myocardial infarction, reduced LV function, and RV dilatation. Implantation of DDD pacemakers prolonged operation time, particularly among operators with a low or medium level of experience. The overall complication rate was 4.5%. Sixty seven per cent of these complications occurred within the first three months. Complication rate was increased by age, reduced LV function, and RV dilatation. Implantation of DDD systems led to a higher complication rate (6.3%) than implantation of VVI (2.6%) or VDD pacemakers (3.2%). These differences were present only among operators with a low or medium level of experience.

Conclusions: Operation time and complication rate increased with age, impaired LV function, and RV dilatation. Complication rates were higher with DDD than with VVI or VDD implantation and were excessive among inexperienced but not experienced operators.

Figure 1

Unadjusted comparison of operation and fluoroscopy times related to device and surgical experience of the operator (level 1, inexperienced; level 2, medium level of experience; level 3, high level of experience). Differences between DDD and VDD or VVI pacemaker implantation decreased with an increasing level of surgical experience but remained significant. *p<0.05.

Figure 2

Independent predictors for a prolonged (left) operation or (right) fluoroscopy time identified by multivariate logistic regression analysis. Right ventricular infarction, need for puncture of the subclavian vein, DDD pacemaker implantation, and the level of surgical experience were independently predictive for both operation and fluoroscopy times that were prolonged above the 75% centile of the patient group. LV, left ventricular.

Figure 3

Univariate comparison of complication rate related to device and surgical experience. There were more complications of implanted DDD pacemakers than of VDD and VVI pacemakers implanted by surgeons with an experience level of 1 or 2 (p < 0.05) but not by experienced operators (level 3). Complication rates of VDD and VVI pacemakers did not differ significantly for any experience level. *Significantly lower than with DDD (p < 0.05).

Figure 4

Independent predictors for an increased complication hazard identified by multivariate Cox regression analysis. Patient age >74 years, right ventricular dilatation, and the level of surgical experience were independently predictive for an increased complication hazard. *Significantly lower than with DDD (p<0.05).