Acute and early complications of permanent pacing: A prospective audit of 926 consecutive patients from a UK center

Abstract

To evaluate the incidence of intraoperative and early postoperative complications (up to 2 months after implant) of endocardial permanent pacemaker insertion in all patients undergoing their first implant at our Center, we prospectively evaluated all pacemaker implantation procedures performed from April 1992 to September 1993. A standard “audit” form was completed at implant, recording patient demographic data, medical history, details of pacemaker hardware used, and any acute complications. Follow-up information was also collected prospectively onto standard forms at the pacemaker outpatient clinic. The study was performed in a United Kingdom tertiary referral Cardiothoracic Center. Nine hundred and fifty consecutive patients underwent implantation of their first endocardial permanent pacemaker from April 1992 to September 1993. Implant and follow-up data to 2 months were available on 926 (97.5%) of these patients at analysis, 51.4% were male (median age 77 years; range 16–99). Dual chamber units were implanted in 53% of patients, single chamber atrial in 6%, and ventricular in 41%. At implant, 23% of patients had a temporary pacing lead in situ. Most (93%) implants were performed via the subclavian vein. Acute complications were rare: 9 patients developed pneumothorax requiring medical treatment and 10 patients developed an insignificant pneumothorax. Arterial puncture without sequelae was documented in 2.7% of attempts at subclavian vein cannulation. Complications requiring re-operation occurred in 3.5% of patients overall; lead displacement [n=14 patients (1.5%)] was the most common reason for re-operation. Atrial lead displacement [n=10 patients (1.85% of atrial leads)] was significantly more common than ventricular lead displacement [n=4 patients (0.46% of ventricular leads), p=0.02]. Pacemaker pocket infection led to reoperation in 9 patients (0.97%) and was significantly more common in patients with a temporary pacing lead at implant (2.35%) compared with those without (0.56%, p < 0.05). Five patients (0.5%) required re-operation for generator erosion and a further 5 (0.5%) for drainage of hematoma or a serous fluid collection. Complications that did not require re-operation occurred in 2.4% of patients overall: atrial (n =8) and ventricular (n=1) undersensing was successfully treated by reprogramming of sensitivity in all cases. Superficial wound infection was treated successfully with antibiotics in eight patients. Six patients with DDD generators developed atrial fibrillation: one was cardioverted, two required reprogramming to VVI mode, and three reverted spontaneously to sinus rhythm. In summary, permanent pacing in a large tertiary referral center with experienced operators carries a low risk. Infection rates are low (<1%). Lead displacement and undersensing are more likely to occur with atrial than with ventricular leads. The overall complication rate for dual chamber pacing is no higher than for single chamber pacing.