Transvenous Pacing Leads and Systemic Thromboemboli in Patients With Intracardiac Shunts A Multicenter Study

• Published in: Circulation (New York, N.Y.) Vol. 113; no. 20; pp. 2391 - 2397
• Main Authors: Khairy, Paul, Landzberg, Michael J., Gatzoulis, Michael A., Mercier, Lise-Andrée, Fernandes, Susan M., Côté, Jean-Marc, Lavoie, Jean-Pierre, Fournier, Anne, Guerra, Peter G., Frogoudaki, Alexandra, Walsh, Edward P., Dore, Annie
• Format: Journal Article
• Language: English
• Published: Hagerstown, MD Lippincott Williams & Wilkins 23.05.2006
• Subjects: Arteriovenous Shunt, Surgical - methods; Biological and medical sciences; Blood and lymphatic vessels; Cardiac Pacing, Artificial; Cardiology. Vascular system; Cardiovascular system; Cohort Studies; Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous; Follow-Up Studies; Heart Defects, Congenital - classification; Heart Defects, Congenital - epidemiology; Heart Defects, Congenital - surgery; Humans; Immunomodulators; Incidence; Intraoperative Complications - epidemiology; Medical sciences; Pacemaker, Artificial; Pharmacology. Drug treatments; Proportional Hazards Models; Retrospective Studies; Thromboembolism - epidemiology; Thromboembolism - surgery; Vasodilator agents. Cerebral vasodilators; Human; pacemakers; shunts; Nervous system diseases; Stroke; Shunt; Multicenter study; Cardiovascular disease; Cerebral disorder; Vascular disease; Pacemaker; Central nervous system disease; heart defects, congenital; Congenital cardiopathy; Cerebrovascular disease; Defibrillator; implantable cardioverter defibrillators
• ISSN: 0009-7322; 1524-4539; 1524-4539
• DOI: 10.1161/CIRCULATIONAHA.106.622076

Background— The risk of systemic thromboemboli associated with transvenous leads in the presence of an intracardiac shunt is currently unknown. Methods and Results— To define this risk, we conducted a multicenter, retrospective cohort study of 202 patients with intracardiac shunts: Sixty-four had transvenous leads (group 1), 56 had epicardial leads (group 2), and 82 had right-to-left shunts but no pacemaker or implantable cardioverter defibrillator leads (group 3). Patient-years were accrued until the occurrence of systemic thromboemboli or study termination. Censoring occurred in the event of complete shunt closure, death, or loss to follow-up. Mean ages for groups 1, 2, and 3 were 33.9±18.0, 22.2±12.6, and 22.9±15.0 years, respectively. Respective oxygen saturations were 91.2±9.1%, 88.1±8.1%, and 79.7±6.7%. During respective median follow-ups of 7.3, 9.3, and 17.0 years, 24 patients had at least 1 systemic thromboembolus: 10 (15.6%), 5 (8.9%), and 9 (11.0%) in groups 1, 2, and 3, respectively. Univariate risk factors were older age (hazard ratio [HR], 1.05; P =0.0001), ongoing phlebotomy (HR, 3.1; P =0.0415), and an transvenous lead (HR, 2.4; P =0.0421). In multivariate, stepwise regression analyses, transvenous leads remained an independent predictor of systemic thromboemboli (HR, 2.6; P =0.0265). In patients with transvenous leads, independent risk factors were older age (HR, 1.05; P =0.0080), atrial fibrillation or flutter (HR, 6.7; P =0.0214), and ongoing phlebotomy (HR, 14.4; P =0.0349). Having had aspirin or warfarin prescribed was not protective. Epicardial leads were, however, associated with higher atrial ( P =0.0407) and ventricular ( P =0.0270) thresholds and shorter generator longevity (HR, 1.9; P =0.0176). Conclusions— Transvenous leads incur a >2-fold increased risk of systemic thromboemboli in patients with intracardiac shunts.