Incidence and predictors of cardiac perforation after permanent pacemaker placement.

BACKGROUND Pericardial effusion, a sign of cardiac perforation, may complicate permanent pacemaker placement. Risk factors for development of post-permanent pacemaker effusion have not been evaluated. OBJECTIVES The purpose of this study was to determine the predictors of symptomatic pericardial effusion after permanent pacemaker placement. METHODS The Mayo Clinic pacemaker and echocardiogram databases were cross-referenced. From 1995 to 2003, 4,280 permanent pacemakers were implanted. Fifty (1.2%) patients developed significant effusion and symptoms consistent with perforation. They were randomly matched with 100 patients without effusion after permanent pacemaker placement. RESULTS The strongest predictors of postimplant effusion by univariate analysis were the concomitant use of a temporary transvenous pacemaker (hazard ratio [HR] 3.2, 95% confidence interval [CI] 1.6-6.2, P = .001) or steroid use within 7 days prior to implant (HR 4.1, 95% CI 1.1-10, P = .003). Weaker predictors were use of helical screw ventricular leads, body mass index (BMI) <20, older age, and longer fluoroscopy times. Variables associated with lower risk of perforation were right ventricular systolic pressure >35 mmHg (HR 0.70, 95% CI 0.44-0.97, P = .01) or BMI >30 (HR 0.62, 95% CI 0.41-0.93, P = .01). Multivariate predictors were use of temporary pacemaker (HR 2.7, 95% CI 1.4-3.9, P = .01), helical screw leads (HR 2.5; 95% CI 1.4-3.8, P = .04), and steroids (HR 3.2, 95% CI 1.1-5.4, P = .04). Right ventricular systolic pressure >35 mmHg was the only protective factor (HR 0.70, 95% CI 0.50-0.92, P = .02). CONCLUSION The incidence of postimplant effusions is low. In order to minimize periprocedural permanent pacemaker effusions, temporary pacemaker placement should be avoided unless essential, and particular care should be taken when placing a permanent pacemaker in patients who are taking steroids.

[1]  E. Beller,et al.  Alterations of Left Ventricular Myocardial Characteristics Associated With Obesity , 2004, Circulation.

[2]  Toru Suzuki,et al.  Oozing from the Pericardium as an Etiology of Cardiac Tamponade Associated with Screw‐In Atrial Leads , 2001, Pacing and clinical electrophysiology : PACE.

[3]  K. Ellenbogen,et al.  Delayed Complications Following Pacemaker Implantation , 2002, Pacing and clinical electrophysiology : PACE.

[4]  I. García-Bolao,et al.  Late Fatal Right Ventricular Perforation as Complication of Permanent Pacing Leads , 2001, Pacing and clinical electrophysiology : PACE.

[5]  M. Irwin,et al.  Postpacemaker Implant Pericarditis: Incidence and Outcomes with Active‐Fixation Leads , 2002, Pacing and clinical electrophysiology : PACE.

[6]  J. Kuruppu,et al.  Delayed cardiac tamponade after pacemaker insertion. , 2000, The Journal of emergency medicine.

[7]  Arthur E. Weyman,et al.  Clinical Correlates and Reference Intervals for Pulmonary Artery Systolic Pressure Among Echocardiographically Normal Subjects , 2001, Circulation.

[8]  R. Twycross.  The Risks and Benefits of Corticosteroids in Advanced Cancer , 1994, Drug Safety.

[9]  R. Hetzer,et al.  Complications of permanent transvenous cardiac pacing. , 1975, The Journal of thoracic and cardiovascular surgery.

[10]  PhilipE. Hill.  Complications of Permanent Transvenous Cardiac Pacing: A 14‐Year Review of all Transvenous Pacemakers Inserted at One Community Hospital , 1987, Pacing and clinical electrophysiology : PACE.

[11]  M. Alpert.  Obesity cardiomyopathy: pathophysiology and evolution of the clinical syndrome. , 2001, The American journal of the medical sciences.