|Year : 2013 | Volume
| Issue : 1 | Page : 3-5
Experience with permanent pacemaker insertion at the University College Hospital, Ibadan, Nigeria
Peter O Adeoye1, Kelechi E Okonta2, Mudasiru A Salami3, Victor O Adegboye3
1 Division of Thoracic and Cardiovascular Surgery, College of Health Sciences, PMB 1515, University of Ilorin, Kwara, Nigeria
2 Department of Surgery, Division of Cardiothoracic Surgery, PMB 5323, University of Port Harcourt, Rivers, Nigeria
3 Department of Surgery, Division of Cardiothoracic Surgery, PMB 5116, University College Hospital, Ibadan, Oyo, Nigeria
|Date of Web Publication||21-Sep-2013|
Kelechi E Okonta
Department of Surgery, Division of Cardiothoracic Surgery, PMB 5323, University of Port Harcourt, Rivers
Source of Support: None, Conflict of Interest: None
Objective: The aim is to determine the characteristics of patients for permanent pacemaker insertion (PPI), treatment outcome, and factors affecting the early insertion of the pacemaker.
Methods: Fifty patients who had permanent pacemaker implanted (PPI) between July 2008 and June 2011 were prospectively followed-up. The patients' demographic data, medical history, details of pacemaker hardware used, complications were collected into a proforma.The data were analyzed using the SPSS Version 17 statistical software package (SPSS, Inc. Chicago Illinois).
Results: During the 3 year period, a total of 50 patients had PPI with a mean age of 66.1 years (ranged 30-88 years). Thirty-three (66%) were males 15 (30%) had hypertension as a co-morbidity, 39 (78%) had complete heart block. In 48 (96%), the cause was not known, 1 (2%) was chloroquine induced. The breakdown of the symptoms showed that syncope accounted for 21 (36.2%), dyspnea 20(34.5%) and recurrent dizziness 9 (15.5%). The pulse rate in 29 (58%) was <40/min. The mean pulse rate 39.4 min (range, 32-65), the mean pre-operation days on admission was 16.09 (ranged 2-60 days) while the mean post-operation days was 7.06 (ranged 2-14 days). The complications included lead dislodgement in 2(4%) patients, infective endocarditis in 1 (2%) and diaphragmatic pacing in 1 (2%). Two (4%) deaths were recorded. The mean survival in months was 14.9 (ranged 12-48 month) during the follow-up.
Conclusion: PPI is well-acceptable in the elderly with improvement in their clinical state. However, plans should be put in place to ensure reduction in the time spent while in the hospital when trying to procure the pacemaker by creating a pacemaker bank in Hospitals that engage in pacemaker insertion in the country.
Keywords: Ibadan, Nigeria, permanent pacemaker implantation, pre-operation hospital stay
|How to cite this article:|
Adeoye PO, Okonta KE, Salami MA, Adegboye VO. Experience with permanent pacemaker insertion at the University College Hospital, Ibadan, Nigeria. Nig J Cardiol 2013;10:3-5
|How to cite this URL:|
Adeoye PO, Okonta KE, Salami MA, Adegboye VO. Experience with permanent pacemaker insertion at the University College Hospital, Ibadan, Nigeria. Nig J Cardiol [serial online] 2013 [cited 2019 Jan 23];10:3-5. Available from: http://www.nigjcardiol.org/text.asp?2013/10/1/3/118572
| Introduction|| |
The GDP of Nigeria is 244 billion United States dollars and income level is lower middle income with a poverty head count ratio at national poverty line of 54.7% (2004),  and health services are not readily affordable.  and the procurement of expensive devices like pacemaker is not readily to come by. Equally, the thinking of severe bradycardia being rare and thus not meriting urgent attention is no true as more and more Nigerians are being diagnosed with this condition.  The etiology of severe bradycardia resulting to the insertion of pacemaker is generally not known.  The fact that there are no prior arrangements for procurement of cardiac pacemaker, the patients stay longer in the hospital trying to raise funds to pay for the cost of implantation. 
| Objective|| |
The aim is to determine the characteristics of patients for permanent pacemaker insertion (PPI), treatment outcome, and factors affecting the early insertion of the pacemaker at the University College Hospital, Ibadan, Nigeria.
| Materials and Methods|| |
Fifty patients who had permanent pacemaker implanted (PPI) between July 2008 and June 2011 were prospectively followed-up. The patients' demographic data, medical history, details of pacemaker hardware used, complications noted, and follow-up information were collected prospectively onto a proforma. The data obtained were analyzed using SPSS Version 17 statistical software (SPSS, Inc. Chicago Illinois). The Patients who could not afford the pacemaker were not included.
| Results|| |
During the 3 year period, a total of 50 patients had PPI. Mean age was 66.1 years (ranged 30-88 years) [Table 1] with 30 (60%) of patients 65 years and above and 33 (66%) were males. In terms of co-morbidities, 15 (30%) had hypertension, 5 (10%) had hypertension with diabetes mellitus and 2 (4%) had prostate cancer at the time of presentation. Indications for PPI showed that 39 (78%) had complete heart block (CHB), 5 (10%) had type 2 s degree heart block (2HB), 4 (8%) had sick sinus syndrome (SSS), and 2 (4%) had trifascular block. In 48 (96%), the cause was not known, 1 (2%) each was chloroquine induced, secondary to chronic hypertension and due to cardiomyopathy. Forty-one (82%) patients were symptomatic; either single or in combination. The breakdown of the symptoms the patients presented with showed that syncope accounted for 21 (36.2%), dyspnea 20 (34.5%), recurrent dizziness 9 (15.5%), chest pain 4 (6.9%), palpitations 3 (5.2%), and non-productive cough 1 (1.7%) [Table 2]. Thirty-one (62%) patients were in NYHA class III/IV while 19 (38%) were NYHA class I/II. The pulse rate in 29 (58%) was < 40/min, in 10 (20%) was 40-60/min and in 11 (22%) was > 60/min. (They were patients with SSS, Trifascicular block, secondary HB).
|Table 1: Age distribution of the 50 patients who had permanent pacemaker Implantation (2008-2011)|
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The lead type was active in 42 (84%) and passive in 8 (16%) with 42 (84%) of the leads being steroid eluting, and 8 (16%) non-eluting. The polarity in 39 (78%) was bipolar and unipolar in 11 (22%). The route of insertion was transvenous in 42 (84%) patients (right 39 and left 3) although it was the epicardial approach in 8 (16%). It was single chamber in 49 (98%) patients and dual chamber in 1 (2%), with VVIR mode in 20 (40%) patients, VVI in 29 (58%) and DDIR in 1 (2%).The mean pre-operation days on admission was 16.09 (ranged 2-60 days) while the mean post-operation days was 7.06 (ranged 2-14) with mean total day on admission of 21.9 (ranged 6-64). Complications include lead dislodgement in 2 (4%) patients, lead exposure with infective endocarditis in 1 (2%) and diaphragmatic pacing in 1 (2%). Two (4%) deaths were recorded. The mean survival in months was 14.9 what (1-4 years ranged).
| Discussion|| |
The mean age at the insertion from our study was 66.7 years and 60% of the patients were 65 years and above. It is important to note that though permanent cardiac pacemakers are implanted in individuals of all ages, it is, however, most often utilized in older adults. , One study observed that up to 70-80% of all pacemakers are implanted in patients 65 years of age or older.  This is attributable to an increase in abnormalities of impulse generation and conduction with advancing age.  The male to female ratio from our study was 2:1. This was at variance with an earlier report from another hospital in Nigeria, a nearby hospital, which reported a female preponderance of 93%.  The co-morbidity in the majority of our patients was hypertension. This is in consonance with finding from another study.  The association between conduction abnormalities and hypertension was previously reported. 
The most common indication was severe bradycardia following CHB. Other reports stated this too. ,, The most common cause of this disorder is not known in greater number of patients. The possible mechanisms are myocardial sclerosis;  however, in one patient (2%) it was strongly associated with chronic chloroquine usage. This important etiology has been reported in the past  in which the history of chronic chloroquine usage was elicited in 73% of the patients. There are many newer and affordable anti-malarias and this makes use of chloroquine less fashionable now. The pulse rate in 29 (58%) was <40/min. A study showed that 64% of the patients' pulse rate was 40 and below.  This was also the finding from our study as 78% of the patients had CHB. The most common symptom was syncopal attack in about 36% closely followed by shortness of breath as this later symptom was present in about 100% of patients reviewed previously in the country. 
The permanent pacemaker was mainly inserted via the transvenous route using the right subclavian route because of the availability of C-arm fluoroscopy in the institution. However, in patient with difficult venous access or failed attempts at the insertion, the epicardial approach is a veritable option.
The longer pre-operate admission period was due to the patients' lack of required financial capability and thus were kept in the hospital for monitoring while funds were being raised for treatment. The National Hospital Insurance Scheme in Nigeria is still rudimentary and PPI is not covered.  Post-operative period was also prolonged because in Nigeria, primary health-care facilities are not entrusted to handle such cases. Furthermore, few institutions perform pacemaker insertion hence some patients come from far distances (>300 km) hence the need to ensure full recovery and initial pacemaker interrogation prior to discharge.
Most of the patients had single lead ventricular pacing, which is generally cheaper than the dual chamber pacing in our setting and coupled with the small size, which offered an advantage for the small sized veins in the age group.  Other reports from Nigeria showed that most patients did well with a single lead ventricular pacing,  though dual chamber pacemakers that maintain synchrony between atria and ventricles are preferable in older patients because of the increased contribution of atrial contraction to ventricular filling in this age group.  However, in most of our patients procurement of the pacemaker is of the economic burden and thus will appreciate a cheaper one which they can do well on. ,, The most common complication was lead dislodgement. This was more with passive leads. Lead dislodgement was the second most common complications in one report after pneumothorax when the subclavian vein was used just like our own study. 
| Conclusion|| |
The implantation of permanent pacemaker is well-acceptable in the elderly with improvement in their clinical state. However, plans should be put in place to ensure reduction in the time spent while in the hospital when trying to procure the pacemaker and before interrogation by creating a pacemaker bank in Hospitals that engage in active pacemaker insertion in the country.
| Acknowledgments|| |
Late Prof. A. O. Adebo for the implantation of pacemaker in some of the patients. All the residents who collected data during the period.
| References|| |
|1.||World Bank. Nigeria: 2012. Available from: http://www.data.worldbank.org/country/nigeria. [Last accessed on 2013]. |
|2.||Vogel RJ. Financing Health Care in Sub-Saharan Africa: Oxford University Press Greenwood Press; 1993. p. 18. |
|3.||Ekpe EE, Aghaji MA, Edaigbini SA, Onwuta CN. Cardiac pacemaker treatment of heart block in Enugu a 5-year review. Niger J Med 2008;17:7-12. |
|4.||Friedberg CK, Donoso E, Stein WG. Nonsurgical acquired heart block. Ann N Y Acad Sci 1964;111:835-47. |
|5.||Thomas MO. Cost issues in pacemaker surgery in Nigeria. Q J Hosp Med 2004;2:140-2. |
|6.||Gregoratos G. Permanent pacemakers in older persons. J Am Geriatr Soc 1999;47:1125-35. |
|7.||Okeahialam BN. The Burden of arrhythmia in hypertension: An electrocardiographic study. Nig J Cardiol 2004;1:53-6. |
|8.||Thomas MO, Oke DA, Ogunleye EO, Adeyanju FA. Bradypacing: Indications and management challenges in Nigeria. Pacing Clin Electrophysiol 2007;30:761-3. |
|9.||Haider R, Meyer JF, Rasul AM. Cardiac pacemakers: Current concepts. Am Fam Physician 1984;29:223-8. |
|10.||Edwards AC, Meredith TJ, Sowton E. Complete heart block due to chronic chloroquine toxicity managed with permanent pacemaker. Br Med J 1978;1:1109-10. |
|11.||Schwartz JB, Zipes DP. Cardiovascular disease in the elderly. In: Bonow RO, Mann DL, Zipes DP, Libby P, editors. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9 th ed., Ch 80. Philadelphia, Pa: Saunders; 2011. |
|12.||Aggarwal RK, Connelly DT, Ray SG, Ball J, Charles RG. Early complications of permanent pacemaker implantation: No difference between dual and single chamber systems. Br Heart J 1995;73:571-5. |
[Table 1], [Table 2]