Treatment of Congenital and Acquired Heart Block with an Implantable Pacemaker RODMAN E. TABER, LUDOVICO R. ESTOYE, EDWARD R. GREEN and THOMAS GAHAGAN Circulation. 1964;29:182-185 doi: 10.1161/01.CIR.29.2.182 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 1964 American Heart Association, Inc. All rights reserved. Print ISSN: 0009-7322. Online ISSN: 1524-4539 The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/content/29/2/182 Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Circulation is online at: http://circ.ahajournals.org//subscriptions/ Downloaded from http://circ.ahajournals.org/ by guest on September 9, 2014 Treatment of Congenlital and Acquired Heart Block with an Implantable Pacemaker By 1R1DMA E. TABE, x M. D., AND LUDOvico R1. Es-royxE-, M.D., EDWARD) 1R. THOMAS GAHAGAN, M.D. REMARKABLE progress hias been made in the management of complete heart l)lock by pacemaking since the experimental work of Callaghan and Bigelowl- in 1951 and the first clinical application iy Zll 2 in 1952. Weirich, Gott, and Lillehei helped pioneer this early phase of pacemaker developmnenit ly stuccessfullly applyinig direct myocardial stimulation to patients withi operatively induiced heart block. Since tlhel, improvements in equipment ancd clinical experience witlh implantal)le pacemakers have been contributed by Glenn,4 Chardackj, Zoll1, and Kantrovi tz.7 The clinical experience to be reported in this presenitation concerns implantation of the Clhardack-Greatlatelh adjuistable rate and culrrent implantable pacemaker * in) 38 patielnlts (fig. 1). M.D., Figure 1 u Iin lhis sertis of pah1e ilmplaintal)le p)a(C make;rscl tienlts showing the battcry contai-inig power-pack(a), electrode tips (b), candl emergency lead (c). Tlhe Surgical Considerations Sinice difficulties with bradyeardia and arrest may oecur dulring induiction of anesthesia and the initial stages of the thoracotomy, it is mandatory that an emergency pacemaking device be in place during this phase of the procedure. Either intravascuilar,9 or precordial pacemaking electrodes may he uised for this pirpose. We lhave foumid the most satisfactory operative approach to he tlhrouiglh a left posterolateral thoracotomy (fig. 2). Upon dischlarge, patients are advised to coutint their pulse once daily and to report a change. The characteristics of the paceinakerare such1 that an increase in rate warns of the need for battery replacement. A metal identification tag which describes the pacemaker ;ate at -d and the voltcage at c( 1it,l1 be acljnstel aifter implantation by inisertiont of the needlc' into the propc r fitting, lc r local anstsia. supplied to he, Oin aroun(l the neck, anid patients are aldvised to carry a (leseription of the ullnit 01] thle,ir persoln. is (:linieal Experienice 13etweeni Decenmiber 1961 ancd September 1963 we lhave used the inplantal)le pacemaker for the mntuagement of heart block in 38 patients. IreHrIt Block. There xvere 34 paAcquire tients in this group anid their ages xvaried from 33 to 85 years. The in-cdications for operation wvere incapacitating syncopal episodes. The heart block was persistent in 30 patients xvhile the remaining fouir exhibited intermittent atrioventricular block with a niodal escape mecha- From the Divisions of Thoracic Surgery and Pediatric Cardiology, Henry Ford Hospital, Detroit, 'Mich- igan. * GREEN, nism (fitg. 3). The type of hleart llock presenit lMe(lironiei, Inc., M\iinneapolis, Minnesota. 182 Cuirldalion, l/ Vol Downloaded from http://circ.ahajournals.org/ by guest on September 9, 2014 e XXY1, Febrta,ry 1964 183 IMPJLANTABL, 1PACEl\AKERL FOIR HIItAIT BLOCK Onec SO-yearol0(1 patienit experielnced faiti1 re N Figure 2 1/it' lOft positero/tateral thoa(lraotoiiiii and tibsnti)tatin(ols )th I incisions art' shitun. The/lcca(btint/nal wall poa trot/cs r.echc Ilc thoracic/c cacity tihiog/li a snl/mcntatIconis tti.nel connlectingl/it' td)tbominalt/i po)tc/h and ithe'11tltriot) c/list twall. in the latter fo()uir patients was detectedl onil by frequeni.t electroecardliographlic examiinations, which illustrates tlhe necessity of performinig repetitive stui(lics in the presence of unexplained svjyicope if this typ)e of (ei)iso(iic lheart block is to be detected. Two patien-ts, aged 33 and 49 years, lhad coexisting calcific aortic steniosis. A pacemaker was implanted at the time of aortic commnissu.irotomIly in oniO case and, in the othleir patient, 5 years after valvilur suirgery. SINUS RHYTHM A-V BLOCK of two Pacemakers of a different (lesign that had been imi)plante(1 elsexwxhere. Slh inlderwent suiccessftul inistallation of a tlhird uinit and lhas been. asymptomatic for 12 moniths. Anioth1er unusaial patient wras I)elieved to have hecart b)lock ovi the basis of metastases to the atrioventricular n1odCe from carciionoma of the 1)reast. Suiccessfuil pacing has continuted in this patient for 18 imonths. Pacemakers were also siccessfully implanted in three patients whi.o had developed complete block at the tim-e of closing interventrieulTar septal defects. Pac.emiiaker failuire occurre(l in one patient in this group, a 9-year-old boy who developed complete heart block of uinknown etiology 3 mnoithis prior to pacemaker implantation. This pacemaker failed owing to 1)reakage of oine of the mvocardial electrode wvires 9 monthis after implaitation aid xvas successfully re- placed. Two patiecits died in the h-ospital. Onie deatlh resulted from-i postoperativxe bleeding folloving aortic commiissuirotoimyvavd pacemaker implan-tationi. The other deatlh resuilted from perforation of a gastric iulcer 7 (lays after operation for the paceemaker. The remaining 32 patients lhave (oIIE well durinig follow-tup periods varyingc from 2 to 24 ioniitlhs. Coneni.ciital IIHeart Block. Fouir patieits, ages 1S, 2W 7, andl 18 years, with co)gemiital NODAL RHYTHM Figure 3 IElcetrocardiogram bcfore and aifier pacema/c'r irnlp)la/ttatzton. Th2e patient exp)erieniced syncope dlue to aslystoicflerf}ont eicar't block tEi/icli was followed byi a nodal escape nechlaniismil. Pactmtzaking tit 60 )eatls per mninttc hats prcientted fuirthler stimptoms. Circulation, Volumc XXIX, Februry 196].: Downloaded from http://circ.ahajournals.org/ by guest on September 9, 2014 TAI3ER ET AL. 184 t)ikseussioll Figure 4 ta't/ia/li l .qI ail cc t in iitl/i tougeujlill fia r t )lo/ tck. e t fip cil/i b e /) nriec/ i t th1(/fi aft/ w hic 1 paet/pc//c s ae to sni/sface of f/li liccd b 1a S- l r hceart block tion. Ilwo episooles and 1/ic' abc/ l/ miiic imlanta- pacemaker tlcm h1ad experience'(d thl' r(emaillilg prog re'ssive caijr(lioioegal> Ile in nni mniet. underxxwent of icict c'arc/iu;n, pliciator is se'c rtcii(1 unit i ccas imip/tinlt'c/ I irn t/ic' uscal l din" own th/ic f/ciip im, t /ic i;al/ child /i-o/c/ icn/tz r sutures'. l toil-sprin g- and (easy fatigui'. xearA-olchild u'l-t block in tlhe nosed oliringt gestati maker did niot prdsecit on. a syncopal (exlhil)itd(' tvo xwas oliag- thle( paceproblem-i in tlhis small The sie of patient (fig. 4). Thlie 7 year old child hiad pacemaker implanited for coexisting congenital lheart block at the timne of closing an initervenitricular septal defect. The 18-y ear- (l patient exhibited procgressixve cardiomegalv oni the basis of cori rected tranl)sosition of the frieamt vessel.s and a comm-iiiioni venitricle in addition to conpgenital heart block. A paceciakeim w'as imnplantel at tle timne of insertinig a prosthietic ventricular septuiim in this patienit. This a pacemaker suil.seqtuently failed becan se( of electroole breakage and xvas replaced, Ibit tle patielit died 3 miotls after the second paco'milaker imil3lantation friom c()io-iplicitioiis of tlle' intracardiac surgoe'ry. A s.ecotidl mortality oce'irr'eol in thiis grouip (of patientts wlmo't tlil' 2/2-yea cl()(1l'lfily -l I)t)stopel rativex ly. imitental died 12 inmn)ltlis e'le'dtr-ical failiure of this hici cewm xxas ol(';no)nst rate r'el)resents the single breakdoxvnm of this tx pe in] ouir experience. T1e remaining txvo patients liave been syviipton-flce(, for )eriods of 10 anod 14 monhthls. Sin]ce satisfactory pacemakers are inow availabie tlhat can be imlplanitecl with minimii al risk to the patient, (lisqelissioni can be focused on the problemn of pa,tient selection. The symptomatic patienit xx iho is exl)erienciVigii syvncopal ('pi sod(de.s presen ts a straiglitforward indicationl for paceimaking. l)eath due to asystole occuirinog in the presence of heart block cain onilv l)e prevented with certainity by this approaclh. The life Spani of pa,.tien ts protecte(l in tlhis maInnier xxwill thein be deterineli(1 Iy the couir-se of their underlyinl cardiac (lisease. It is less clear to x hlat extent use of the pacemaker should l)e rc''omniendedl for- the patient wvithl lheart block that is inot accomipanied by syvicope. Txvo of ouir patieits wvithi congrenital leart l)lock presented1 this finidinig. Paiemaking wras establishled in botl inf.stances because of progressive car-dioniieszalv. The managemenlit of stiiuirgicatllv finducedl acri.t block accomipanvylig intracar(liac surgery is lbcst perfornmed by pacing tli (xighl temporary myva(rdliail electrodes implanted a,t tle cornpletionl of pen-hert surgery. Sille soml-e of thiesc patienlts coinlert to a sinus ineciuiism inl fr-omil a fexv hl0ouris to a fexv xveeks following, openi-heart surgery, imiplantation of a permnanent ulilit slholild be xvithhield uintil the irrex ersibilityT of the dissociation is apparent. A fev patients undergoing open-lheart suirgery7 for initracardiac lesions have pre-existilng lheart block. W\7e have encouintered this combiniationi as conigenital heart block accomipanyingl ventrilcular- septal defects and as acqiuirel block ini the presence of calcific aortic sten(osis. The likelilhood of recoxecry folloxing op)een-lhear.t suri.gical r-epair of these lesions wouild seem greacter if a more niormal heart riate is insired ouring the postoperative periodi bI siimutltanleoso f)pacemaker iimiplantllastiono. S u n iina rv '11e~~~~1 Illl o Il ld (hatdttild(-'k (4eaCtba)(tch inlanl|(ltablo'l PiICt('m-aker- hlas prov ed a xx orthiwli le (levice for tlIc imianiagemenit of botlh conigeniital anid acquired lheart block. Tlhe procedure tised for iinplanitationi in 38 patienits is described. T1e mnost frequielit indication for u-se of the pacemaker is synlcope dute to heart block. ProgresCi}(rcdllon,D Volums<Ze XIX"'1.' FebZrnary 1964 Downloaded from http://circ.ahajournals.org/ by guest on September 9, 2014 IMPLANTABLE PACEMAKER FOR HEART BLOCK sive cardiac enlargement was also an indication for pacemaker implantation in two of four children with congenital heart block. The pacemaker has also been useful in the management of surgically induced heart block and coexisting heart block that accompanies intracardiac lesions, such as aortic stenosis, which require open-heart surgery. Pacemaker failure due to electrode breakage occurred in two patients. In both instances, a replacement unit was successfully used. Three of the 38 patients have subsequently died from causes unrelated to pacemaking while one death resulted from pacemaker failure 12 months after implantation. The remaining 34 patients have remained free from cardiac symptoms during observation periods of 2 to 24 months. References 1. CALLAGHAN, J. C., AND BIGELOW, W. G.: An electrical artificial pacemaker for standstill of the heart. Ann. Surg. 134: 8, 1951. 2. ZOLL, P. M.: Resuscitation of the heart in ventricular standstill by external electric stimulation. New England J. Med. 247: 768, 1952. 185 3. WEIRICH, W. L., GOTT, V. L., AND LILLEHEI, C. W.: The treatment of complete heart block by the combined use of a myocardial electrode and an artificial pacemaker. Surg. Forum 8: 360, 1957. 4. GLENN, W. W. L., MAURO, A., LONGO, E., LAVIETES, P. H., AND MACKAY, F. J.: Remote stimulation of the heart by radiofrequency transmission. New England J. Med. 261: 948, 1959. 5. CHARDACK, W. M., GAGE, A. A., AND GREATBATCH, W.: Correction of complete heart block by a self-contained and subcutaneously implanted pacemaker: Clinical experience with 15 patients. J. Thoracic & Cardiovas. Surg. 42: 814, 1961. 6. ZOLL, P. M., FRANK, H. A., ZARSKY, L. R. N., LINENTHAL, A. J., AND BELGARD, A. H.: Longterm electric stimulation of the heart for Stokes-Adams disease. Ann. Surg. 154: 330, 1961. 7. KANTROWITZ, A., COHEN, R., RAILLARD, H., SCHMIDT, J., AND FELDMAN, D. S.: The treatment of complete heart block with an implanted, controllable pacemaker. Surg. Gynec. & Obst. 115: 415, 1962. 8. PARSONNET, V., ZUCKER, I. R., GILBERT, L., AND MAXIM, A. M.: An intracardiac bipolar electrode for interim treatment of complete heart block. Am. J. Cardiol. 10: 261, 1962. Auscultation Auscultation though in practice and in our minds dating from Laennec and the invention of the stethoscope was not an absolutely new idea in 1819. The Hippocratic School applied the ear to the chest and were familiar with pleuritic friction and succussion. Harvey listened to the sounds of the heart, Robert Boyle (1627-91) is said also to have done so, and a little later Robert Hooke (16051703), as told in his posthumous works published in 1705 by Richard Waller, listened to the heart and realized, but did not pursue, the possibilities of this method of obtaining information about the movements of the viscera. Laennec believed that G. L. Bayle (1774-1816), Corvisart's assistant when he worked under him, was the first of the moderns to practise the immediate or Hippocratic auscultation by putting his ear on the chest, and stated that Corvisart listened to the heart sounds with his ear very close to but not actually in contact with the chest wall.-SIR HUMPHRY DAVY ROLLESTON. The Harveian Oration. Great Britain, Cambridge University Press, 1928, p. 74. Circulation, Volume XXIX, February 1964 Downloaded from http://circ.ahajournals.org/ by guest on September 9, 2014