Patient Presentation
A third year medical student was rotating on her general pediatric clerkship and saw a toddler with an atrial septal defect that had closed. A conversation regarding congenital heart disease with her attending ensued. She said, “When I was doing internal medicine I had several patients that had pacemakers. I know kids can get pacemakers but what are the indications? In adults it’s usually heart failure.” The attending said he wasn’t entirely sure but general categories would include arrhythmias that needed pacing, heart failure, and probably for transitions to other care such as after heart surgery or as a bridge to transplant. The medical student did a PUBMED search and found a couple articles that she shared with the attending pediatrician.
Discussion
More pediatric patients are having cardiac pacemakers and implantable cardioverter defibrillators (ICDs) placed because the devices are becoming smaller and are technically feasible plus the surgical complexity of patients also keeps increasing. Pacemakers have an impulse generator and leads. The leads can be placed uni- or bilaterally and are attached to the endo- or epicardium. The generator is placed in the left pectoral area. Complications include lead dislodgement or breakage, and inappropriate shocks. Other problems include need for lead or generator revisions, lifestyle modifications, and cosmetic changes. ICDs are like pacemakers but can also defibrillate tachyarrhythmias.
Patients and families of children with pacemakers and ICDs demonstrated decreased quality of life scores compared to healthy controls and also patients with congenital heart disease (CHD) without the devices. For patients with pacemakers, self-perception is the main element in the lower quality of life.
Learning Point
Indications for pacemaker implantation from the American Heart Association:
-
“
- Class I – Pacemaker implantation indicated
- Advanced second/third-degree AV block with symptomatic bradycardia, ventricular dysfunction, or low cardiac outputs or that persists at least 7 days postcardiac surgery
- Symptomatic age-inappropriate sinus bradycardia
- Congenital third-degree AV block with wide QRS, complex ventricular ectopy, or ventricular dysfunction
- Congenital third-degree AV block in an infant with HR < 55 beats/minute or <70 beats/minute in infants with CHD
- Class IIa: Pacemaker implantation reasonable
- Patients with CHD, sinus bradycardia and intra-atrial reentry tachycardia
- Asymptomatic sinus bradycardia in child with complex CHD with resting HR 3 seconds
- Patient with CHD and impaired hemodynamics because of sinus bradycardia and loss of AV synchrony
- Unexplained syncopy with repaired CHD patient complicated by transient AV block with residual fasicular block
- Class IIb: Pacemaker implantation may be considered
- Transient postop AV block that reverts to sinus rhythm with residual bifasicular block
- Congenital third-degree AV block in asymptomatic child/adolescent with acceptable rate, narrow QRS complex, and normal venticular function
- Asymptomatic sinus bradycardia after biventricular repair of CHD with resting HR 3 seconds
- Class III: Pacemaker implantation not effective/contraindicated
- Transient postop AV block that reverts to normal AV conduction
- Asymptomatic Type 1 AV block
- Asymptomatic sinus bradycardia in adolscent with resting HR > 40 beats/minute and longest R-R interval < 3 seconds
- Asymptomatic postop bifasicular block in the absense of transient complete AV block”
Questions for Further Discussion
1. What are indications for ICD implantation?
2. What are the causes of syncope?
3. What is familiar long QT syndrome and what treatments are available?
Related Cases
- Symptom/Presentation: Genetic Disorder
- Specialty: Cardiology / Cardiovascular-Thoracic Surgery
- Age: Toddler
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Pacemakers and Implantable Defibrillators
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Epstein AE, DiMarco JP, Ellenbogen KA, et al. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities. J Am Coll Cardiol. 2008;51(21):e1-e62.
Villain E. Indications for pacing in patients with congenital heart disease. Pacing Clin Electrophysiol. 2008 Feb;31 Suppl 1:S17-20.
van Geldorp IE, Vanagt WY, Prinzen FW, Delhaas T. Chronic ventricular pacing in children: toward prevention of pacing-induced heart disease. Heart Fail Rev. 2011 May;16(3):305-14.
Navaratnam M, Dubin A. Pediatric pacemakers and ICDs: how to optimize perioperative care. Paediatr Anaesth. 2011 May;21(5):512-21.
ACGME Competencies Highlighted by Case
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
16. Learning of students and other health care professionals is facilitated.
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital
Pediatric Education 