Original-clinicalIncidence and predictors of cardiac perforation after permanent pacemaker placement
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.
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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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