The incidence of coronary artery compression in children fitted with epicardial pacemakers may be slightly more common than previously believed. After reviewing patient records at Boston Children's Hospital, they advocate for stricter monitoring to identify patients at risk and prevent complications. The study was published in the journal HeartRhythm, the official journal of the Heart Rhythm Society and the Cardiac Electrophysiology Society.

Children who require pacemakers or defibrillators often need to have wires placed on the outside of their heart due to their size or unique anatomy. In rare instances, these wires can place the child at risk for "cardiac strangulation," which can lead to compression of the heart muscle and coronary arteries (the blood vessels that feed the heart) over time.

Coronary Artery Compression

Coronary artery compression is thought to be rare. Its true incidence, however, may be higher than we believed due either to a lack of awareness or lack of reporting in the literature. The sudden death of a child with an epicardial pacemaker following coronary artery compression prompted investigators to enhance surveillance of all patients with epicardial pacing or defibrillation systems.

Epicardial Leads

Of 145 patients, eight (5.5%) exhibited some degree of coronary compression from their epicardial leads. Six of these patients displayed symptoms; in addition to the case of sudden death, there were three cases of chest pain and two cases of unexplained fatigue. As a result of the review, seven patients underwent surgical removal or repositioning of their epicardial leads.

Epicardial Pacemakers

This study helps provide a framework for monitoring patients with epicardial pacemakers or defibrillators and identifying those who may need revision or removal of their epicardial wires.

They found that chest X-ray had a high specificity and was a good screening tool, easy to perform, inexpensive, and non-invasive. However, it can produce some false-negatives even when patients were symptomatic.

The authors propose that patients with concerning chest x-rays, symptoms such as unexplained chest pain or tiredness, or evidence of heart muscle damage or dysfunction should ideally have a cine CT scan that can image the heart moving about the epicardial wires. 

Pacemakers

If cine CT is not available, they advocate that patients undergo catheter angiography to confirm the diagnosis before taking a patient to surgery. The use of pacemakers and defibrillators in children is growing. As more epicardial devices are implanted, more children may be at risk for developing coronary compression from their leads. 

They hope to increase awareness among healthcare providers and patients of this important, possibly preventable, and potentially fatal complication and provide a useful screening algorithm to detect at-risk patients and ultimately prevent complications.

Chest X-ray

Dr. Serwer emphasizes that all cardiologists who have patients with epicardial electrodes should always be aware of this potential complication and periodically assess patients for coronary issues with at least a periodic chest X-ray. When evidence strongly suggests ischemia secondary to coronary compression due to electrode position, electrode replacement must be considered given the potential morbidity and mortality.

The author concludes that strongly concur with the authors that any additional information one can obtain to aid in risk assessment would be of benefit and agree with them that additional studies to establish the efficacy of nuclear cardiology techniques are indicated.