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Background: Pacing-induced cardiomyopathy (PICM) is an important cause of heart failure in patients with a right ventricular pacing burden. Recent evidence suggests that an upgrade to cardiac resynchronization therapy (CRT) may confer benefit in PICM. Objective: To assess the extent and identify predictors of improvement following upgrade to CRT in patients with PICM. Methods: We retrospectively analyzed 43 patients undergoing CRT upgrade for PICM over the 10-year period of 2011 to 2021 at our center. All patients with PICM who underwent device upgrade from a dual- or single-chamber ventricular pacemaker to CRT were included. PICM was defined as a decrease of ≥10% in left ventricular ejection fraction (LVEF), resulting in an LVEF <50% among patients with ≥20% Right ventricular pacing burden without an alternative cause for cardiomyopathy. Results: LVEF significantly improved from 28.7% preupgrade to 44.3% post-CRT upgrade (P < .01). Of 37 patients with severe LV dysfunction, 34 (91.9%) improved to an LVEF >35% and 13 (35.1%) improved to an LVEF >50%. The LV end-diastolic diameter decreased from 5.9 cm preupgrade to 5.4 cm postupgrade (P < .01). Using linear regression, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use was associated with significant LVEF improvement (+7.21%, P = .05). We observed a low rate of complications, and 1 in 4 CRT upgrades required venoplasty (n = 10 of 43, 23.3%). Conclusion: We provide further evidence for the benefit of CRT upgrade in the management of patients with PICM.

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INTRODUCTION: Superior vena cava (SVC) tear is the most lethal complication during transvenous lead extraction (TLE) with a mortality rate as high as 50%. Treatment involves aggressive attempts to maintain cardiac output and immediate sternotomy to localize and repair the vascular tear. Occlusion balloons have been developed to provisionally occlude the lacerated SVC and to provide hemodynamic stability allowing time for surgery. In case of mediastinal hematoma without hemodynamic instability, the strategy remains unclear. METHODS AND RESULTS: We describe two cases of SVC tear during TLE. The first case was a 60-year-old man who presented with a right ventricular single-chamber defibrillator lead fracture and innominate vein stenosis. The RV lead was removed using a laser sheath causing a mediastinal hematoma with no active bleeding during surgical exploration few hours later. The second case was a 28-year-old man that presented with a right atrial (RA) lead fracture and RV lead insulation failure in a dual-chamber defibrillator (ICD). CONCLUSION: Both the RA and RV leads were removed with mechanical sheaths, and a mediastinal hematoma was medically managed.

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BACKGROUND: Cardiac implantable electronic devices (CIED) are very rare in the pediatric population. In children with CIED, transvenous lead extraction (TLE) is often necessary. The course and effects of TLE in children are different than in adults. Thus, this study determined the differences and specific characteristics of TLE in children vs. adults.Methods and Results: A post hoc analysis of TLE data in 63 children (age ≤18 years) and 2,659 adults (age ≥40 years) was performed. The 2 groups were compared with respect to risk factors, procedure complexity, and effectiveness. In children, the predominant pacing mode was a single chamber ventricular system and lead dysfunction was the main indication for lead extraction. The mean implant duration before TLE was longer in children (P=0.03), but the dwell time of the oldest extracted lead did not differ significantly between adults and children. The duration (P=0.006) and mean extraction time per lead (P<0.001) were longer in children, with more technical difficulties during TLE in the pediatric group (P<0.001). Major complications were more common, albeit not significantly, in children. Complete radiographic and procedural success were significantly lower in children (P<0.001). CONCLUSIONS: TLE in children is frequently more complex, time consuming, and arduous, and procedural success is more often lower. This is related to the formation of strong fibrous tissue surrounding the leads in pediatric patients.

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OBJECTIVES: Permanent pacemakers are widely used in the pediatric population due to congenital and surgically acquired rhythm disturbances. The diversity and complexity of congenital heart diseases make device management a highly individualized procedure in pediatric pacing. We are also faced with special problems in pediatric age group as growth, children's activity and infection susceptibility. This study aimed to present our institute's experience in pediatric and adolescent pacemaker implantation and long-term outcomes. METHODS: This cross-sectional observational study included 100 pediatric patients who visited our outpatient clinics at Ain Shams University Hospitals for regular follow up of their previously implanted permanent pacemakers. All patients were subjected to history taking, clinical examination, ECG recording, echocardiography and elaborate device programming. Data about device types, device components' longevity, subsequent procedures, complications were collected, with comparison between epicardial and endocardial pacemakers. RESULTS: Our study population ranged in age from 8 months to 18 years (mean 13.12 ± 5.04 years), 51 were males and 53 patients had congenital heart disease. Epicardial pacing represented 26% of our total population using only VVIR pacemakers, while endocardial pacing represented 74% of our population with 58.1% of them being VVIR pacemakers. First battery longevity was higher in endocardial batteries (108 months vs. 60 months, p value: 0.007). First lead longevity was also higher in endocardial leads (105 moths vs. 58 months, p value: 0.006). Complication rate was 25%; 8 patients had early complications (one insulation break in endocardial group). Late complications occurred in 17 patients (10 patients had lead fracture; 9 of them were endocardial, 2 insulation breaks in endocardial leads, 3 patients from epicardial group had lead failure of capture). In total, 16 patients had lead-related complications. There was no statistically significant difference between different lead models regarding lead-related complications. CONCLUSION: Pacemakers in children are generally safe, but still having high rates of lead-related complications. Lead failure of capture was more common in epicardial leads. These complications had no relation to the model of the leads. Endocardial pacemakers showed higher first lead and first battery longevity compared to epicardial pacemakers.

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BACKGROUND: Open surgical implantation of epicardial leads in neonates and infants remains the first option of treatment. We reviewed the long-term outcomes after epicardial pacemaker implantation in neonates and infants. METHODS: From 1989 to 2016, 48 patients (16 neonates) underwent pacemaker implantation within the first year of life. Their median age and weight were 66.5days (range: 0∼319 days), and 4.2kg (range: 1.9∼9.3kg), respectively, at the time of first pacemaker implantation. The indications for pacemaker implantation were postoperative or congenital atrioventricular block, sinus node dysfunction, and/or myocarditis-induced atrioventricular block. Forty-six (46) unipolar epicardial leads (non-steroid-eluting: 22; steroid-eluting: 24) and two bipolar leads (steroid-eluting) were inserted using a median sternotomy or subxiphoid approach. RESULTS: The mean follow-up duration was 8.5±7.9years. The most commonly used generator mode at first implantation was VVI (n=24, 50.0%). Eleven (11) generator mode changes from the initial VVI or VVIR to dual-chamber pacing were made at a mean of 7.0±6.2years after the first implantation for better inter-chamber synchrony and ventricular function. Freedom from reoperation for generator change after the first implantation was 95.3, 70.6, and 21.9% at 1, 5, and 10 years. Eighteen (18) lead malfunction events (34.1%) were detected. Freedom from reoperation for lead change was 97.8, 76.2, and 46.3% at 1, 5, and 10 years. The lead replacement rate was significantly higher in patients with non-steroid-eluting than steroid-eluting leads (p=0.045). CONCLUSIONS: Neonates and infants require more frequent changes in pacemaker generator and leads than the older population. The use of steroid-eluting leads increased lead longevity and reduced the need for surgical re-interventions.

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Management of patients with cardiac implantable electronic devices (CIEDs) has become complex given the complications that can occur with implanted lead systems. Clinical problems such as infection, lead failure, and occluded vessels create situations that demand intervention to remove leads. Due to adhesions that occur in the venous system and at the endomyocardial attachment site, simple traction to remove a lead is often not sufficient. Infection is a mandatory reason to remove the entire CIED system. Tools and techniques are now available that enable a skilled operator to extract leads with a great deal of efficacy and safety.

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The transvenous implantation of cardiac devices may sometimes cause serious complications involving the coronary arteries. The left anterior descending artery may be injured during nonapical right ventricular implantation while a right atrial lead may injure the right or circumflex coronary artery. Injury of a left internal mammary graft to a coronary artery may cause myocardial infarction.

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UNLABELLED: Few studies have characterized the surgical outcomes following epicardial pacemaker placement in very low-birth weight infants with congenital complete heart block. This study was undertaken to review the surgical experience with this patient population based on data from a large multi-institutional registry. METHODS: The Pediatric Cardiac Care Consortium (PCCC) multi-institutional database was retrospectively reviewed to identify premature, low-birth weight neonates that underwent surgical placement of an epicardial pacing system for heart block. We reviewed 179 patients with birth weights less than 1.5 kg that underwent a major operative procedure. Of these, 10 patients underwent surgical placement of an epicardial pacing system for heart block. Patients had heart block in otherwise structurally normal hearts (n = 6) or heart block associated with complex structural congenital cardiac anomalies (n = 4). RESULTS: There were no deaths directly related to the surgical placement of the epicardial pacing system. There were no immediate complications with either lead or generator placement. One generator pocket was revised three months following placement. Survival to discharge was 60%. The four deaths occurred at a mean of 11 days (range 1-45 days) following the procedure. CONCLUSIONS: Neonates born with prematurity and congenital heart block represent a challenging subset of patients with significant mortality. Generator pocket breakdown and infection have been considered barriers to optimal short- and long-term outcomes. Among cases in the PCCC, there were no deaths or major complications that could be attributed to permanent epicardial pacemaker placement. These data suggest that an aggressive surgical strategy may be justified.