196/Does the implantation of atrial epicardial pacing wires during cardiac surgery carry the risk of significant bleeding requiring surgical intervention in the post-operative period?

Introduction: Post cardiac surgery, the management of haemodynamics in the ITU can be significantly influenced by appropriately programmed, temporary dual chamber pacing. More specifically, there should be a high importance placed on maintaining atrio-ventricular synchrony in patients who are already haemodynamically compromised. However, the surgical placement of an atrial wire intra-operatively must be balanced against the potential increased risk of bleeding in the post-operative period. Limited contemporary date exists on extent of these risks.

Method: We conducted a single centre retrospective audit of all patients who underwent cardiac surgery in a high-volume tertiary referral centre between August 2017 and May 2019. All patients with temporary dual chamber epicardial wires were included. Patients returning to theatre for emergency re-sternotomy in the post-operative period for significant bleeding were identified and post-surgical transcripts reviewed. If no post-surgical transcript was available patients were excluded.

Results: A total of 3,670 patients were assessed. Of these, 130 (3.54%) returned to theatre due to bleeding. 28 patients were excluded due to either not having pacing wires in situ, or the post procedure report was not available. Of the patients included, 81 were male aged mean ± 67.2. Eighty-three (81%) had atrial epicardial pacing wires in situ. Causes of bleeding included epicardial pacing wire 1% (1), bleeding from a suture line 13.7% (14), bleeding/oozing from sternal wires 8.8% (9), anastomotic bleeds 7.8% (8), mammary bed bleeds 7.8% (8), cannulation site bleeds 3.9% (4), other bleeding sites (1 entry, each) 9.8% (10). In 50% (51) of patients, no obvious source of bleeding was found. Median time from initial procedure to re-sternotomy was 12 hours (IQ range 7–23).

Conclusion: In our cohort, we find the incidence of re-sternotomy directly related to the presence of atrial epicardial pacing wires in the post-operative period to below. In particular, only one patient required surgical intervention directly associated with a temporary epicardial pacing lead. Therefore, based on these results, clinicians should not be unduly concerned about the bleeding risks associated with surgical atrial epicardial lead placement in patients that would benefit from the maintaining of atrio-ventricular synchrony.