The danger of coronary artery compression in children is more common than we think

August 13, 2018, Elsevier
The danger of coronary artery compression in children is more common than we think
Images of the different imaging techniques used to diagnose one of the patients who displayed symptoms. Chest x-ray in the posterioranterior (A) and lateral (B) projections, showing the classic pattern of cardiac strangulation from epicardial leads, as the ICD lead courses leftward and posterior around the heart. Computed topography (C) shows the ICD lead constricting the left ventricle and obtuse marginal branch of the circumflex artery. Catheter angiography (D) shows loss of contrast within the obtuse marginal branch as it courses below the ICD lead. Credit: HeartRhythm

The incidence of coronary artery compression in children fitted with epicardial pacemakers may be slightly more common than previously believed, say noted cardiologists. After reviewing patient records at Boston Children's Hospital, they advocate for stricter monitoring to identify patients at risk and prevent complications. Their recommendations are published as a featured article 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 is thought to be rare," explained lead investigator Douglas Y. Mah, MD, director of the Pacemaker and ICD Program in the Department of Cardiology, Boston Children's Hospital, and assistant professor of pediatrics, Harvard Medical School, Boston, MA, USA. "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 compression prompted investigators to enhance surveillance of all patients with epicardial pacing or defibrillation systems. They reviewed the records of all patients followed at Boston Children's Hospital from 2000-2017 who had either active or abandoned epicardial wires that included coronary imaging, either by computed topography (CT) scan or catheter angiography through the vessels in the leg. Of 145 patients, eight (5.5 percent) 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.

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. Dr. Mah and colleagues compared three screening techniques. They recommend that pediatric patients with epicardial devices should get screening chest x-rays every few years to assess how their wires look in relation to their heart, as the positioning may change as the child grows. 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 or tiredness, or evidence of heart muscle damage or dysfunction should ideally have a cine CT scan that can image the heart moving in relation to the epicardial wires. Although this can also result in a false-positive, CT is less risky for pediatric patients because radiation doses are now much lower for this non-invasive imaging method.

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," noted Dr. Mah. "As more epicardial devices are implanted, more children may be at risk for developing coronary compression from their leads. We 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."

"This article clearly emphasizes the need to not only carefully evaluate the potential site of electrode head fixation to avoid coronary injury, but also the need to evaluate closely where to route the electrode body to the device pocket," commented Gerald A. Serwer, MD, FHRS, pediatric cardiologist at the University of Michigan's C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI, USA, in an accompanying editorial.

Dr. Serwer emphasizes that all cardiologists who have patients with epicardial electrodes should always be aware of this potential complication and periodically assess 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 in view of the potential morbidity and mortality. "I 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," concluded Dr. Serwer.

Explore further: Study shows leadless pacemaker patients experience less complications

More information: Douglas Y. Mah et al, Coronary artery compression from epicardial leads: More common than we think, Heart Rhythm (2018). DOI: 10.1016/j.hrthm.2018.06.038

Gerald A. Serwer. More epicardial electrode issues to remember, Heart Rhythm (2018). DOI: 10.1016/j.hrthm.2018.06.040

Related Stories

Study shows leadless pacemaker patients experience less complications

June 26, 2018
Patients receiving leadless pacemakers experience overall fewer short-term and mid-term complications than those receiving traditional transvenous pacemakers, a Cleveland Clinic-led research study found. The study was published ...

Epicardial fat tissue thickness predicts coronary artery disease

August 3, 2012
(HealthDay) -- Asymptomatic patients with coronary artery disease (CAD) have significantly more epicardial adipose tissue (EAT) than those without CAD, with an average EAT thickness of 2.4 mm or higher predictive of significant ...

Cardiac hybrid imaging an effective tool for predicting heart attacks

July 3, 2018
Cardiac hybrid imaging with CT and nuclear stress testing is an excellent long-term predictor of adverse cardiac events like heart attacks in patients being evaluated for coronary artery disease, according to a study published ...

Low risk with normal coronary arteries, nonobstructive CAD

April 5, 2013
(HealthDay)—Patients who experience acute chest pain, and have nonobstructive coronary artery disease (CAD), as determined by coronary computed tomographic angiography, have similarly benign outcomes as those with normal ...

Certain heart fat associated with higher risk of heart disease in postmenopausal women

January 30, 2017
A higher volume of a certain type of fat that surrounds the heart is significantly associated with a higher risk of heart disease in women after menopause and women with lower levels of estrogen at midlife, according to new ...

Recommended for you

Research team traces pathway to cardioprotection in post-ischemic heart failure

December 11, 2018
During an ischemic attack, the heart is temporarily robbed of its blood supply. The aftermath is devastating: reduced heart contractility, heart cell death, and heart failure. Contributing to these detrimental changes is ...

Workplace exposure to pesticides and metals linked to heightened heart disease risk

December 11, 2018
Workplace exposure to metals and pesticides is linked to a heightened risk of heart disease in Hispanic and Latino workers, reveals research published online in the journal Heart.

Macrophage cells key to helping heart repair—and potentially regenerate, new study finds

December 11, 2018
Scientists at the Peter Munk Cardiac Centre have identified the type of cell key to helping the heart repair and potentially regenerate following a heart attack.

Study reveals new link between atrial fibrillation and mutations in heart disease gene

December 11, 2018
Atrial fibrillation (Afib), a heart condition that causes a rapid, irregular heartbeat that increases a person's risk of stroke and heart failure, is fairly common among older adults. However, its early onset form is relatively ...

Researchers have found that incidence of heart failure was around two-fold higher in people with diabetes

December 11, 2018
Researchers have found that incidence of heart failure was around two-fold higher in people with diabetes.

Study: Age, race differences determine risk of stroke in women and men

December 11, 2018
A new study found that, between the ages of 45 and 74 years, white women were less likely to have a stroke than white men, but at age 75 and older, there was no difference in stroke risk between white women and men. In contrast, ...

0 comments

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.