Commentary: An ounce of prevention is worth a pound of cure
2021; Elsevier BV; Volume: 7; Linguagem: Inglês
10.1016/j.xjtc.2021.03.022
ISSN2666-2507
Autores Tópico(s)Cardiac Arrhythmias and Treatments
ResumoCentral MessageA novel, minimally invasive technique for epicardial sutured permanent pacing leads adds an additional intervention option. The complexity of intervention choices highlights the need to avoid complete heart block whenever possible.See Article page 245. A novel, minimally invasive technique for epicardial sutured permanent pacing leads adds an additional intervention option. The complexity of intervention choices highlights the need to avoid complete heart block whenever possible. See Article page 245. Complete atrioventricular heart block is morbid; whether it manifests as a congenital heart block or a postoperative complication. Pediatric patients account for approximately 1% of all permanent pacemaker implants.1Lotfy W. Hegazy R. AbdElAziz O. Sobhy R. Hasanein H. Shaltout F. Permanent cardiac pacing in pediatric patients.Pediatr Cardiol. 2013; 34: 273-280Crossref PubMed Scopus (17) Google Scholar This population presents a clinical challenge as many children are either too small or have cardiac or vascular anatomies which prohibit the traditional transvenous approach of lead placement. In this issue of JTCVS Techniques, Nellis and colleagues2Nellis J.R. Alsarraj M.K. Sauer J.S. Klapper J.A. Idriss S.F. Turek J.W. A minimally invasive approach for atrial and ventricular sew-on epicardial lead placement.J Thorac Cardiovasc Surg Tech. 2021; 7: 245-248Scopus (3) Google Scholar describe a novel, minimally invasive approach for epicardial lead placement in children. The authors are to be commended for developing an additional technique to address this challenging management situation. Their approach focuses on placement of sutured epicardial leads via video-assisted thoracoscopy (VATS), negating the need for thoracotomy or sternotomy. The authors report the use of this approach in 5 patients, with lead placement successful in 4 of these attempts. Although initial threshold voltages for the leads were elevated, the performance of the leads was stable after more than 1 year of follow-up. The single failed patient required conversion to a thoracotomy with subsequent successful lead placement. This failure was in a patient with hypoplastic left heart syndrome post–total cavopulmonary completion (Fontan procedure). Although the report represents a small sample of patients, this failure does give pause regarding the ability to use this technique in the most complex patients. Nonetheless, further attempts are warranted, as these complex patients may require an additional learning curve beyond that of the general surgical technique. A greater concern remains regarding the need for permanent pacing. Rates of heart block after congenital heart surgery that require permanent pacing are reported in 1% of all cases3Liberman L. Silver E.S. Chai P.J. Anderson B.R. Incidence and characteristics of heart block after heart surgery in pediatric patients: a multicenter study.J Thorac Cardiovasc Surg. 2016; 152: 197-202Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar; however, the reported rates of postoperative complete heart block are quite high in certain operations, at 15.6% after double switch and 7.8% after tricuspid valve replacement.3Liberman L. Silver E.S. Chai P.J. Anderson B.R. Incidence and characteristics of heart block after heart surgery in pediatric patients: a multicenter study.J Thorac Cardiovasc Surg. 2016; 152: 197-202Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Two of the patients in this report required permanent pacing after congenital heart surgery. A reduced rate of postoperative heart block will obviate the need for pacing and its associated complications and multiple reinterventions. In our experience, rates of postoperative heart block can be reduced to near zero across many intervention types.4Mery C.M. Zea-Vera R. Chacon-Portillo M.A. Zhang W. Binder M.S. Kyle W.B. et al.Contemporary results after repair of partial and transitional atrioventricular septal defects.J Thorac Cardiovasc Surg. 2019; 157: 1117-1127.e4Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 5Mery C.M. Zea-Vera R. Chacon-Portillo M.A. Zhu H. Kyle W.B. Adachi I. et al.Contemporary outcomes after repair of isolated and complex complete atrioventricular septal defect.Ann Thorac Surg. 2018; 106: 1429-1437Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 6Scully B.B. Morales D.L.S. Zafar F. McKenzie E.D. Fraser Jr., C.D. Heinle J.S. Current expectations for surgical repair of isolated ventricular septal defects.Ann Thorac Surg. 2010; 89 (discussion 550-1): 544-549Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar The minimally invasive approach described by Nellis and colleagues is an important add-on to our armamentarium, particularly in patients in whom permanent pacing is unavoidable, such as with congenital heart block. This technique will likely require a learning curve for congenital cardiac surgeons who infrequently perform VATS procedures within their normal practice. Further evaluation is needed to determine appropriate patient selection criteria to reduce the risk of failure of this technique, particularly in patients with complex anatomy and surgical history. The need for new approaches as well as new devices (leads and pacing devices) is indeed warranted, but perhaps even more important is the refinement of our surgical expertise and avoidance of complete heart block to the point of viewing its occurrence as a never event in congenital heart surgery. A minimally invasive approach for atrial and ventricular sew-on epicardial lead placementJTCVS TechniquesVol. 7PreviewPermanent pacemaker (PPM) placement in pediatric patients is rare. Indications for permanent pacing in children include congenital and postsurgical atrioventricular block, symptomatic sick sinus syndrome, and select neuromuscular disorders.1,2 PPMs are traditionally placed using transvenous systems in adults and larger children. However, young children are often not suitable candidates due to their size or history of congenital cardiac surgery. Full-Text PDF Open Access
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