Interventional cardiology

Consider long term implications of pacemakers in younger adults: Australian experts

Cardiologists need to carefully consider the benefits of pacemaker insertion in younger patients and ensure close follow-up of recipients, according to local clinicians who highlight the increasing complication rates reported with long term follow up.

Generator and lead malfunctions requiring reoperations are among the long term complications faced by younger adults receiving a pacemaker, according to a Melbourne study,

The review of 81 consecutive patients (18–50 yrs) undergoing pacemaker implantation at The Alfred Hospital between 1986–2020 for indications such as AV block, found a long term complication rate of 14%.

These included lead malfunction, lead migration, insulation breach and pacemaker failure.

“Although lead migration accounts for a small proportion of complications, this occurred within a much shorter time frame of 2.9 years on average,” the study said.

“This complication could therefore occur multiple times throughout the life of the pacemaker, and patients would require multiple reoperations with the associated risks each time.”

The study, published in Heart, Lung and Circulation, said the higher rate of device malfunction compared to other studies probably reflected a significantly longer follow-up period.

A further 11% of patients experienced pacemaker-related morbidity from inadequate lead performance managed with device reprogramming. Much of the morbidity occurred more than 10 years after pacemaker insertion.

The study found 56% of patients had arrhythmias detected during follow-up and 17% had a pacemaker mediated cardiomyopathy (PMC) with deterioration in left ventricular ejection fraction (LVEF) by more than 10%.

The investigators said most complications and lead performance issues occurred in pacemakers inserted between 1986 and 2001 rather than later in the study period.

“While this may be due to less sophisticated hardware in these early devices, this trend may also be explained by these patients having longer to develop symptoms and complications.”

They said younger adults with pacemakers should be followed closely for development of clinically significant arrhythmias “which may herald development of new structural heart disease and may prompt consideration of upgrade to a defibrillator”.

The study also found minimal pacemaker utilisation with pacing <5% at all checks in 19% of patients and pacing less than 1% in 10% of patients.

“The identification of these patients who had pacemakers inserted but not utilised highlights the importance of rigorous evaluation in younger adults prior to pacemaker insertion, particularly in light of the higher incidence of vasovagal syncope in younger adults.”

They concluded that pacemaker insertion in younger adults has significant long-term implications.

“Clinicians should carefully consider pacemaker insertion in this cohort given risk of device-related complications, potential for device under-utilisation and issues related to lead longevity. In addition, patients require close follow-up for development of structural abnormalities and arrhythmias.”

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