Clinical implications of temporary permanent pacemakers
Balloon-tipped temporary pacemakers (BTTP) are associated with an increased risk of dislodgement due to lead instability in the right ventricle.(6,9) This increases the risk of loss of capture, requiring lead repositioning or replacement.(6,9,12) For this reason, in current clinical practice, most patients undergoing balloon-tipped temporary pacemaker placement are admitted to the intensive care unit for close and frequent monitoring.(10,13) This was reflected in our study, where none of our BTTP subjects were placed outside the intensive care unit while having the temporary pacemaker inserted. On the other hand, active fixation of the lead into the myocardium provides more stability, less risk of dislodgement and eventual loss of capture. Our data shows it is safe to monitor patients with TPPM outside the ICU setting, unless patient’s condition otherwise necessitates ICU admission.
On average, patients with TPPM were paced for a longer duration than patients with BTTP. One possible explanation of this observation is that active fixation offers greater stability and safety, permitting a longer observation duration before inserting a permanent pacemaker, or until the underlying reversible condition is resolved. Importantly, patients with TPPM were paced for up to 10 days on the general medical ward outside the ICU. Using TPPM instead of BTTP helped save 160 total ICU days in our cohort of patients, resulting in salutary implications for the patient as well as reduced utilization of healthcare resources and resultant cost savings. Temporary pacing with active leads may save hospitals more ICU bed-days, resulting in decreasing cost of hospitalization and giving opportunity to better care for patients with several conditions requiring ICU admissions. For example, this can be crucial in scenarios similar to the COVID 19 pandemic, with historic difficulties in bed availability and staffing. In addition, prolonged ICU stay can be associated with significant morbidity and mortality,(12,14-16) including increased risk of hospital acquired infections (pneumonia,(17) urinary tract infections(18)), deep venous thrombosis, stress ulcers, and death.(19,20) ICU associated delirium and severe deconditioning are also frequently seen among patients hospitalized in the ICU.(21,22)
On the contrary, BTTP lead instability renders ambulation extremely risky, and thus patients with a BTTP remain bedridden with close monitoring until the pacemaker is safely replaced or removed. Prior studies related to temporary pacemakers with active fixation leads (TPPM) have reported increased ambulation among patients with TPPM.(8,23,24) Our study showed similar results regarding patient ambulation. Almost half of our TPPM cohort were ambulating while being paced, whereas none of the BTTP patients were ambulatory while needing the temporary pacemaker A significant contributor to this observation was the vascular access site, the majority of BTTP patients had femoral access, which renders mobility impractical, compared to subclavian or jugular access. The ability of mobilizing patients early on gives TPPM a significant advantage over BTTP since early mobility is associated with many benefits among hospitalized adults.(25) Immobility is associated with increased risk of venous thromboembolism, deconditioning, increased hospital length of stay, and higher in-hospital mortality rates.(26)