Cardiac Pacing and Defibrillation in Pediatric and Congenital Heart Disease

Maully Shah, Larry Rhodes, Jonathan Kaltman, Maully Shah, Larry Rhodes, Jonathan Kaltman

• Publisher: Wiley-Blackwell
• Year: 2017
• Print ISBN: 9780470671092
• eBook ISBN: 9781119333036
• Edition: 1
• Topic: Medicine
• Subtopic: Physiology

With a growing population of young patients with congenital heart disease reaching adulthood, this unique new book offers an in-depth guide to managing the challenges and issues related to device therapy in this patient group.

• The only book resource dedicated to pacing, cardiac resynchronization therapy and ICD therapy for the pediatric and congenital heart disease patient 
• Contains practical advice for pacemaker and ICD implantation, programming, trouble-shooting, managing complications and follow up 
• Up-to-date with the latest in device technology
• Contains multiple graphics, device electrogram tracings, and radiographic images for clarity 
• Includes video clips and over 150 multiple choice questions with extended answers on companion website, ideal for self test
• An invaluable resource for both the specialist pediatric cardiologist and the general cardiologist responsible for children with heart disease and pacing devices

Part 1
Introduction

Chapter 1
History of cardiac pacing and defibrillation in the young

Larry Rhodes¹ and Robert Campbell²

¹Chair, Department of Pediatrics, Robert C. Byrd Health Sciences Center, Professor of Pediatrics, WVU School of Medicine, Morgantown, WV, USA

²Pediatric Cardiologist, Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Professor of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA

The earliest years of cardiac pacing predate the birth of many current pediatric cardiac electrophysiologists. An old saying states that “failure to understand history dooms one to repeat it.” In contrast, understanding this history of successful collaboration between pioneering physicians and engineering partners allows us to marvel at the developments that were to follow rapidly over the next 50 years, and potentially repeat this formula in years to come.

Benjamin Franklin harnessed electricity from lightning using a kite in 1752. An early “medical” use of electricity was not to augment life but to document the end of it with patients receiving an electrical shock to prove they were dead. In 1774, electrical energy was applied to resuscitate a child using a transthoracic approach.¹ As early as 1899, the British Medical Journal published a report of experiments demonstrating that application of electrical impulses to the human heart would lead to ventricular contractions.² In 1926, Dr. Mark C. Lidwell and physicist Edgar H. Booth of Sydney developed a device with pacing rates of 80–120 bpm and outputs varying from 1.5 to 120V.³ This “pacer” was described as being a portable device “plugged into a lighting point.” One pole was connected to a pad soaked in strong salt solution and applied to the skin and the other, “a needle insulated except at its point, was plunged into the appropriate cardiac chamber.” In 1928, this apparatus was used to revive a stillborn infant whose heart continued to beat after 10 minutes of stimulation.⁴

During the 1930s, Dr. Albert Hyman noted that the success of intracardiac delivery of medications for cardiac arrest was likely independent of the medication but was instead related to the needle stick leading to alteration in electrical potentials and myocardial contraction. Knowing that multiple needle sticks would be impractical and dangerous, he developed a generator to deliver electrical impulses via needle electrodes.⁵

Following World War II there was a significant interest in pacemakers generated by investigations in the use of general hypothermia for cardiac surgery. Cardiac arrest was noted during hypothermia and adequate heart rate was required to maintain adequate hemodynamics during rewarming. John A. Hopps, an engineer at the National Research Council of Canada developed a pacemaker that produced impulses at a desired rate through an electrode placed in the area of the sinus node.⁶

In 1952 Dr. Paul M. Zoll used an external pacemaker coupled with transcutaneous needle electrodes to rescue a patient suffering from Stokes-Adams attacks following a myocardial infarction.^7,8 The patient continued to experience ventricular asystole despite being administered 34 intracardiac injections of adrenaline over a 4-hour period. Dr. Zoll applied “external electrical stimulation” and successfully paced this patient's heart over the next 25 minutes.⁸ The patient developed cardiac tamponade secondary to perforation of a cardiac vein during the intracardiac injections. Dr. Zoll then successfully paced a 65-year-old man with episodes of ventricular standstill for 5 days by external electrical stimulation at which time he developed an idioventricular rhythm at 44 bpm and was discharged.⁹

In the mid-1950s, open heart surgery was becoming a reality. Although for the first time in history, intracardiac palliation of structural heart disease was possible, the complication of surgical heart block was a significant morbidity. Dr. W. Lillehei, Dr. W. Weirich, and others at the University of Minnesota demonstrated that pacing could be performed by connecting a pulse generator to a wire electrode attached directly to the heart of a dog.^10,11 In January 1957, Lillehei used this pacing system in the first human patient, a child with post-operative heart block following repair of a ventricular septal defect. The pacer was programmed to a pulse width of 2ms and a voltage ranging from 1.5 to 4.5V (Figure 1.1).¹²

Figure 1.1 Patient pushing pacemaker cart (1958). (Source: Reproduced with permission of Medtronic, Inc.)

The generators used by both Zoll and Lillehei were devices which transformed alternating current into direct current to pace the heart. In 1957, following a power failure in Minneapolis in which patients could not be paced, Dr. Lillehei enlisted the help of Earl Bakken and Medtronic for battery backup for AC pacemakers. Silicon transistors had become commercially available in 1956 leading to the potential for development of smaller and more practical pacemakers. The original transistorized, zinc oxide battery-powered external pacemaker was developed by Mr. Bakken in 1957; the device was smaller and thus applicable for pediatric patients.^13,14 This, the first wearable external pacemaker, was housed in a small plastic box, with controls to allow adjustment of pacing rate and voltage (Figure 1.2).

Figure 1.2 Wearable pulse generator (1958). (Source: Reproduced with permission of Medtronic, Inc.)

Although novel and potentially lifesaving, the advances described here were not a long term solution in that there was a significant risk of infection and external pacing was uncomfortable and impractical. There was a definite need for implantable pacing systems. Ake Senning, a Swedish surge...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• Table of Contents
• Foreword
• List of Contributors
• Preface
• About the Companion Website
• Part 1: Introduction
• Part 2: Clinical Concepts
• Part 3: Implantation Techniques
• Part 4: Device Programming and Follow-Up
• Glossary
• Index
• End User License Agreement