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)