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J Thorac Cardiovasc Surg 2007;134:515-516
© 2007 The American Association for Thoracic Surgery

Brief Communication

The utility and safety of temporary pacing wires in postoperative patients with congenital heart disease

Jose M. Moltedo, MDa,d, Geoffrey L. Rosenthal, MDb, Jeffrey Delaney, MDc,d, Dennis Mello, MDd,f, Christopher S. Snyder, MDd,e,*

a Section of Pediatric Cardiology, FLENI Institute, Buenos Aires, Argentina
b Division of Pediatrics, Section of Pediatric Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio
c Division of Pediatrics, Section of Pediatric Cardiology, Duke University, Durham, NC
d Division of Pediatrics, Section of Pediatric Cardiology, Yale University School of Medicine, New Haven, Conn
e Division of Pediatrics, Section of Pediatric Cardiology, Ochsner Clinic Foundation, New Orleans, La
f Section of Pediatric Cardiovascular Surgery, Connecticut Children’s Hospital, Hartford, Conn.

Received for publication November 27, 2006; revisions received January 2, 2007; accepted for publication January 8, 2007.

* Address for reprints: Christopher S. Snyder, MD, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121. (Email: csnyder{at}ochsner.org).

Arrhythmias constitute a common complication after cardiovascular surgery (CVS) in pediatric patients.1-3Go Pacing wires are helpful in the differentiation and treatment of supraventricular, ventricular, and sinus tachycardia. The purpose of this study was to determine (1) whether pacing wires are useful in the diagnosis and treatment of early postoperative arrhythmias, (2) whether any factors exist to predict patients who benefit from their placement, and (3) the complications associated with their placement, use, or removal.

Clinical Summary

A single-center, institutional review board–approved, prospective observational study was performed. Inclusion criteria were as follows: patient age of less than 18 years and CVS between September 2000 and March 2003. Exclusion criteria were a patent ductus arteriosus ligation or coarctation of the aorta repair because wires were not placed. Data collected included cardiopulmonary bypass (CPB) and aortic crossclamp (AXC) times, pacing wire placement and location, use of pacing wires, and complications. Before chest tube removal and transfer from the intensive care unit, wires were removed by a pediatric cardiology fellow.

The Student test and {chi} analysis, along with simple and multiple logistic regression analysis, were used to make comparisons.

A total of 209 patients met the inclusion criteria: 170 (81%) having pacing wires, 159 (93.5%) having atrial and ventricular wires, 10 (5.9%) having ventricular wires, and 1 having atrial pacing wires. Wires were used in 59 (35%) patients: 33 for diagnostic purposes, 11 for therapeutic purposes, and 15 for both purposes.

Comparisons between group 1, those with pacing wires, and group 2, those without pacing wires, found a significant difference in CPB time (123.8 vs 46.1 minutes) and AXC time (59.5 vs 18.5 minutes,) P < .0001).

Splitting group 1 into those who used their pacing wires (group 1A) versus those who did not (group 1B), direct relationships were found between longer AXC time (81.4 vs 47.9 minutes, P < .0001) and CPB time (151.3 vs 109.1 minutes, P < .0006). Further analysis of group 1A, dividing it into those who used the wires for therapeutic, diagnostic, or both therapeutic and diagnostic purposes versus group 1B found that both AXC and CPB times increased (Table 1).


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  		TABLE 1 Comparisons between groups
 
For every 10-minute increase in AXC time, the odds of therapeutic use of the pacing wires increased by 27% (95% confidence interval [CI], 16%–40%). For each 10-minute increase in CPB, the odds of therapeutic use of the pacing wires increases by 13% (95% CI, 7%–20%). When AXC and CPB times were entered into the model simultaneously, only AXC time was an important predictor of therapeutic use of pacing wires.

In our group of patients, no complications related to the placement, use, or removal of wires was noted. The 95% CI around the estimate of complication rate is 0% to 1.2%. None of the patients in whom wires were not placed experienced an arrhythmia. The surgeons were able to predict with 100% accuracy the patients not requiring pacing wires but only 26% (59/170) of those patients who would.

Discussion

This study found the incidence of use of pacing wires to be equal to 26% for post-CVS pediatric patients. Of those operations in which pacing wires were placed, the percentage of use increased to 35%, with more than half (56%) for diagnostic purposes.

When analysis was performed to evaluate the need for pacing wires (diagnostic, therapeutic, or both), 2 predictors fell out: length of AXC and CPB time. When the group of patients with pacing wires was further analyzed, therapeutic and diagnostic versus all other, significantly longer AXC and CPB times were noted as predictors. When comparisons were made between pacing wires used for therapeutic and diagnostic purposes, the only difference was in the AXC time (98.3 vs 65.7 minutes).

Although this study does not determine patients who require pacing wires, it does provide some guidelines. Patients whose AXC times, CPB times, or both are longer might benefit from placing pacing wires at the time of CVS. With each 10-minute increase in AXC or CPB time, a significant increase, 27% and 13%, occurred in the therapeutic use of pacing wires. These findings, longer AXC and CPB times, might simply be variables of the surgical complexity of the case. Despite anecdotal reports of complications associated with pacing wires, no complications were noted with the placement, use, or removal in this study.

Patients with longer CPB and AXC times associated with more complicated surgical procedures have a significantly higher chance of requiring pacing wires for their postoperative management. In addition, their placement, use, and removal appear to be safe.

References

  1. Pfammatter JP, Bachmann DCG, Wagner BP, et al. Early postoperative arrhythmias after open heart procedures in children with congenital heart disease. Pediatr Crit Care Med 2001;2:217-222.[Medline]
  2. Valsangiacomo E, Schmid ER, Schupbach RW, et al. Early postoperative arrhythmias after cardiac surgery in children. Ann Thorac Surg 2002;74:792-796.[Abstract/Free Full Text]
  3. Delaney J, Moltedo J, Dziura JD, et al. Early postoperative arrhythmias after cardiac surgery in children. J Thorac Cardiovasc Surg 2006;131:1296-1300.[Abstract/Free Full Text]



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