Elsevier

Heart Rhythm

Volume 2, Issue 9, September 2005, Pages 907-911
Heart Rhythm

Original-clinical
Incidence and predictors of cardiac perforation after permanent pacemaker placement

https://doi.org/10.1016/j.hrthm.2005.06.011Get rights and content

Background

Pericardial effusion, a sign of cardiac perforation, may complicate permanent pacemaker placement. Risk factors for development of post-permanent pacemaker effusion have not been evaluated.

Objectives

The purpose of this study was to determine the predictors of symptomatic pericardial effusion after permanent pacemaker placement.

Methods

The Mayo Clinic pacemaker and echocardiogram databases were cross-referenced. From 1995 to 2003, 4,280 permanent pacemakers were implanted. Fifty (1.2%) patients developed significant effusion and symptoms consistent with perforation. They were randomly matched with 100 patients without effusion after permanent pacemaker placement.

Results

The strongest predictors of postimplant effusion by univariate analysis were the concomitant use of a temporary transvenous pacemaker (hazard ratio [HR] 3.2, 95% confidence interval [CI] 1.6–6.2, P = .001) or steroid use within 7 days prior to implant (HR 4.1, 95% CI 1.1–10, P = .003). Weaker predictors were use of helical screw ventricular leads, body mass index (BMI) <20, older age, and longer fluoroscopy times. Variables associated with lower risk of perforation were right ventricular systolic pressure >35 mmHg (HR 0.70, 95% CI 0.44–0.97, P = .01) or BMI >30 (HR 0.62, 95% CI 0.41–0.93, P = .01). Multivariate predictors were use of temporary pacemaker (HR 2.7, 95% CI 1.4–3.9, P = .01), helical screw leads (HR 2.5; 95% CI 1.4-3.8, P = .04), and steroids (HR 3.2, 95% CI 1.1–5.4, P = .04). Right ventricular systolic pressure >35 mmHg was the only protective factor (HR 0.70, 95% CI 0.50–0.92, P = .02).

Conclusion

The incidence of postimplant effusions is low. In order to minimize periprocedural permanent pacemaker effusions, temporary pacemaker placement should be avoided unless essential, and particular care should be taken when placing a permanent pacemaker in patients who are taking steroids.

Introduction

Permanent pacemaker implantation may be complicated by cardiac perforation, which can lead to longer hospital stays, tamponade, or even death.1, 2, 3, 4 The incidence of perforation after permanent pacemaker reportedly is between 0.5% and 2%, but the predictors of perforation have not been defined.5, 6

The clinical manifestations of significant perforations are variable and include chest pain, dyspnea, and hypotension. These signs, in conjunction with a new pericardial effusion immediately following permanent pacemaker implantation, suggest a permanent pacemaker-related cardiac perforation. We analyzed cardiac perforation as an acute complication of permanent pacemaker implant and evaluated the incidence and predictors of this complication.

Section snippets

Methods

The Mayo Clinic Rochester echocardiography and pacemaker implantation and databases from January 1, 1995 through December 31, 2003 were electronically searched. Data were reviewed in a manner consistent with Mayo Institutional Review Board requirements. Patients identified from the databases as having undergone permanent pacemaker placement for any reason, who developed clinical signs or symptoms consistent with perforation, and had an echocardiogram revealing a previously undiagnosed

Results

During the analyzed time period from 1995 through 2003, 4,280 permanent pacemakers were implanted at our center. Seventy-four patients (1.7%) had clinical signs of perforation and an effusion within 7 days of permanent pacemaker placement. Twenty-two of these patients had either recent cardiac surgery or a known pericardial effusion prior to permanent pacemaker implantation and were excluded from this analysis. Two minors also were excluded. The remaining 50 patients (1.2%) were included in the

Discussion

This study confirms that cardiac perforation as defined by symptoms and new pericardial effusion is an uncommon complication of permanent pacemaker implantation. Independent predictors of cardiac perforation following permanent pacemaker implantation are temporary pacemaker use, administration of oral steroids within the preceding 7 days, and use of an active fixation helical screw lead in the right ventricle. Elevated right ventricular systolic pressure appears to be protective against

Conclusion

Independent predictors of cardiac perforation as a complication of permanent pacemaker implantation include oral steroid use in the 7 days preceding permanent pacemaker implantation, use of a temporary pacemaker in association with permanent pacemaker implantation, and use of a helical screw active fixation lead in the right ventricle. Pulmonary hypertension is associated with a reduced risk of cardiac perforation as a complication of permanent pacemaker implantation.

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