Surgical approaches to epicardial pacemaker placement: does pocket location affect lead survival?

Abstract

Permanent cardiac pacing in pediatric patients presents challenges related to small patient size, complex anatomy, electrophysiologic abnormalities, and limited access to cardiac chambers. Epicardial pacing currently remains the conventional technique for infants and patients with complex congenital heart disease. Pacemaker lead failure is the major source of failure for such epicardial systems. The authors hypothesized that a retrocostal surgical approach would reduce the rate of lead failure due to fracture compared with the more traditional subrectus and subxiphoid approaches. To evaluate this hypothesis, a retrospective chart review analyzed patients with epicardial pacemaker systems implanted or followed at Rady Children's Hospital San Diego between January 1980 and May 2007. The study cohort consisted of 219 patients and a total of 620 leads with epicardial pacemakers. Among these patients, 84% had structural congenital heart disease, and 45% were younger than 3 years at time of the first implantation. The estimated lead survival was 93% at 2 years and 83% at 5 years. The majority of leads failed due to pacing problems (54%), followed by lead fracture (31%) and sensing problems (14%). When lead failure was adjusted for length of follow-up period, no significant differences in the rates of failure by pocket location were found.

Fig. 1

Chest radiographs demonstrating pocket locations. The typical sites of epicardial pacemaker implantation are demonstrated from left to right: retrocostal, subxiphoid, and subrectus. Notably, the retrocostal location keeps all hardware within an intrathoracic location, whereas the subrectus and subxiphoid pacemaker pockets require that the pacemaker leads traverse the abdominal musculature

Fig. 2

Kaplan–Meyer survival curve for epicardial pacemaker leads by pocket location. Cumulative lead longevity, defined as freedom from lead failure for any reason, does not differ between retrocostal, subrectus, and subxiphoid pacemaker pocket locations (p = 0.491, Mantel-Cox)

Fig. 3

Bar graph showing the cause of lead failure by pocket location expressed as the proportion of total lead failures. When lead failure is stratified by cause, groups do show statistical differences based on their epicardial pacemaker pocket location (retrocostal vs subrectus vs subxiphoid; p = 0.194, Pearson chi-square)

Fig. 4

Kaplan–Meyer survival curve for epicardial pacemaker leads by (non)steroid elution. For all leads for all pacemaker pocket locations, comparison of steroid-eluting leads with non–steroid-eluting leads shows no significant difference in lead longevity (p = 0.244, Mantel-Cox)