Temporary window of opportunity for an urgent pacemaker implantation program available 24/7
R Bergel Garcia, J Hernandez-Hernandez, J L Morinigo, M Sanchez-Garcia, P L Sanchez-Garcia, J Jimenez-CandilAbstract
Introduction and objectives
Most complications that appear in patients with acute symptomatic bradycardia (ASB) occur during the waiting period until permanent pacemaker implantation (PPI). Published data show that a Program for Urgent Permanent Pacemaker Implantation (UPPI) available 24 hours a day, 7 days a week (UPPI-24/7) is associated with a significant reduction in pre-implantation morbidity. Our objective is to define a Temporal Window of Opportunity (TWO) by analyzing the effectiveness of the program based on patient age and delay to implantation.
Methods
This is an observational and prospective analysis of 664 subjects aged ≥60 years with ABS undergoing PPI, in two consecutive 18-month periods: implants during working hours (PPI-WH) (n=341) and UPPI-24/7 (n=323). Median time to implant was 13 hours (PPI-WH) vs. 3 hours (UPPI-24/7). We classified individuals according to their age into 2 groups: ≥80 years (n=378) and <80 years (n=249). We defined five-time intervals from ASB diagnosis to PPI: 0-6 hours (T1), 7-12 (T2), 13-18 (T3), 19-24 (T4), and >24 h (T5).
Results
The cumulative incidence of pre-implantation complications (Pre-I-Comp) was 48/664 (7.2%), being higher in patients ≥80 years of age (8.9% vs. 4.4%; p=0.03). Figure 1 shows that Pre-I-Comp frequency increases with delay to implantation (p<0.001 for trend), and it was higher in all time intervals in subjects ≥80 years of age. Among this population, almost 50% had Pre-I-Comp at T5. UPPI-24/7 was associated with a significant reduction in Pre-I-Comp (2.5% vs. 12%; adjusted p <0.001). Delirium (0.6 vs. 3.8%; p=0.007), recurrence of symptomatic bradyarrhythmia (0 vs. 6.5%; p<0.001), torsades des pointes (0.3 vs 1.3%; p=0.3) and infections not device-related (1.9% vs, 4.4%; p=0.07) were less frequent in UPPI-24/7. As shown in the figure 2, the maximum absolute risk reduction of Pre-I-Comp associated with UPPI-24/7 is obtained at T1 (around 10% in both age groups). However, the absolute risk reduction at T2 is significant only in ≥80 years.
Conclusions
Among patients with ABS, Pre-I-Comp incidence increases linearly with time from diagnosis to PPI. A program of UPPI-24/7 is associated with a significantly reduction in Pre-I-Comp. The ideal TWO for an UPPI-24/7 program is 6 hours; in patients aged ≥80 years, benefits are obtained up to 12 hours.Frequency of Pre-I-Comp