Is there a correlation between late re-exploration after cardiac surgery and removal of epicardial pacemaker wires?
© The Author(s). 2017
Received: 24 February 2016
Accepted: 19 January 2017
Published: 25 January 2017
Re-exploration for bleeding accounts for increased morbidity and mortality after major cardiac operations. The use of temporary epicardial pacemaker wires is a common procedure at many departments. The removal of these wires postoperatively can potentially lead to a serious bleeding necessitating intervention.
From Jan 2011 till Dec 2015 a total of 4244 major cardiac procedures were carried out at our department. We used temporary epicardial pacemaker wires in all cases. We collected all re-explorations for bleeding and pericardial tamponade from our surgical database and then we focused on the late re-explorations, meaning on the 4th postoperative day and thereafter, trying to identify the removal of the temporary pacemaker wires as the definite cause of bleeding. Patients’ records and medication were examined.
Thirty-nine late re-explorations for bleeding, consisting of repeat sternotomies, thoracotomies and subxiphoid pericardial drainages, were gathered. Eight patients had an acute bleeding incidence after removal of the temporary wires (0.18%). In four of these patients, a pericardial drainage was inserted, whereas the remaining patients were re-explorated through a repeat sternotomy. Two patients died of the acute pericardial tamponade, three had a blood transfusion and one had a wound infection. Seven out of eight patients were either on dual antiplatelet therapy or on combination of aspirin and vitamin K antagonist.
A need for re-exploration due to removal of the temporary pacemaker wires is a very rare complication, which however increases morbidity and mortality. Adjustment of the postoperative anticoagulation therapy at the time of removal of the wires could further minimize or even prevent this serious complication.
KeywordsCardiac surgery Epicardial pacemaker wires Pericardial tamponade Re-exploration
The use of temporary epicardial pacemaker wires (EPW) after cardiac procedures is a standard routine at many cardiac surgical departments . These temporary wires are removed postoperatively after a stable cardiac rhythm has been established. A rare but potentially hazardous complication of removal of these wires is the development of a cardiac tamponade necessitating the re-exploration of the patient [1–3]. The exact incidence of this complication remains uncertain, whereas its prevention in the era of dual antiplatelet therapy (DAPT) and modern anticoagulant medicaments, such as novel oral anticoagulants (NOACs), seems to be challenging.
The time point of removal of these EPW is generally dependent upon surgeon’s preference. At our institution, the use of temporary epicardial pacemaker wires is a standard and these are routinely removed on the 4th to 5th postoperative day (POD) by patients in stable cardiac rhythms, whereas in cases of transient atrioventricular block or new postoperative atrial fibrillation demanding electrical or pharmaceutical cardioversion the wires are taken out later. Although careful monitoring of coagulation by means of laboratory measurement of the international normalized ratio (INR) and the activated partial thromboplastin time (aPTT) is standard before removing of the wires, cases of pericardial bleeding are coming up sporadically.
The aim of our work was to gather all confirmed and suspicious cases of pericardial tamponade after removal of EPW and to estimate the frequency of this complication. We also studied the patient’s medications, in order to find a possible correlation, trying to avoid or minimize this risk.
From Jan 2011 till Dec 2015, a total of 4244 major cardiac operations have been performed at our department. Paediatric surgical procedures have been excluded from our review.
We collected all reoperations for bleeding and pericardial draining after cardiac surgery in this time period and then we focused on the late procedures, meaning on the 4th POD and thereafter, in order to coincide with the removal of the EPW. As a late re-exploration, we defined a full repeat sternotomy, thoracotomy, thoracoscopy and subxiphoid pericardial drainage insertion.
Variables used in our database for searching were bleeding, mediastinal bleeding, reoperation for bleeding, pericardial tamponade, haematothorax and haematoma evacuation either through resternotomy or thoracotomy/thoracoscopy, and subxiphoid pericardial drainage insertion. Reoperations for bypass revision, wound healing disorder or sternal wound infection, secondary closure of a sternotomy, extreme critical procedures with mechanical support of the heart postcardiotomy and chest left open were excluded from this review.
Primary cardiac operations by all late re-explorations for pericardial tamponade (n = 39)
Type of operation (n = 28)
CABG + MV repair/replacement
CABG + AV repair/replacement
Left ventricular assist device
AVR + MV/TV repair/replacement
AVR + MV replacement + CABG
Defining the exact cause of bleeding in the late re-explorations seemed to be complicated, as in many cases no active bleeding could be found. The removal of the epicardial pacemaker wires could be recognized as the definite cause of bleeding in only 8 cases of the total of 4244 patients (0.2%), accounting for 3.6% of all re-explorations for bleeding.
List of re-explorations for bleeding after EPW removal
ASA + VKA + Hep.
INR = 1.3 PTT = 99
ASA + VKA + Hep.
INR = 1.9 PTT = 41
Blood transfusion (RBC 2 packages)
ASA + VKA
INR = 2.2
DAPT + LMWH
Blood transfusion (RBC 2 packages)
DAPT + LMWH
INR = 1.3 PTT = 30
Blood transfusion (RBC 2 packages) Wound complications
INR = 1.2 PTT = 28
MV repair, occlusion LAA
DAPT + VKA + Hep.
INR = 2.0 PTT = 38
AVR + CABG + aorta asc. replac.
ASA + VKA + Hep.
INR = 1.8 PTT = 32
The analysis of patients’ medication revealed that, two patients were on DAPT with aspirin and clopidogrel and low molecular weight heparin (LMWH), four were on combination of aspirin with phenprocoumon and heparin as bridging, one patient was on DAPT and vitamin K antagonist (VKA) and one on LMWH as antithrombotic prophylaxis. The INR of patients on phenprocoumon lied between 1.2 and 2.2, whereas aPTT control by patients who were on unfractionated heparin, as bridging till attainment of the optimal INR, was normal by the time of EPW removal with one exception (aPTT > 60). Three from these eight patients needed a blood transfusion due to bleeding, whereas a sternal wound infection after resternotomy in one patient led to a latissimus dorsi plasty (Table 2).
Additionally, our data revealed six highly suspicious cases, which were readmitted in our institution after the 15th POD while on rehabilitation, due to massive pericardial effusion and clinical deterioration. Three of these patients were reexplored through resternotomy and three received a subxiphoid pericardial drainage. All of these patients were discharged after the primary cardiac procedure without an echocardiographic finding of a pericardial effusion and all patients were on VKA and/or aspirin. In three patients, a derailment of anticoagulation (INR >5) was verified. In five patients, the pericardial effusion was older haemorrhagic and in one case it was serous, without blood elements. The outcome of these patients was unproblematic, with the exception of one patient, who developed superficial wound healing complications, demanding a slightly prolonged hospital stay. It remains of course uncertain whether these cases of late pericardial tamponade could be attributed to removal of the EPW.
Re-explorations for acute bleeding or haematoma evacuation are relatively frequent after major cardiac procedures, especially as modern guidelines recommend operating patients on aspirin or even on DAPT, for example in coronary surgery . Reopening of a sternotomy potentially complicates wound healing, prolonging hospital stay and elevating costs . Removal of the temporary EPW can potentially complicate the postoperative course of a cardiac surgical patient through acute bleeding and pericardial tamponade, nevertheless the exact incidence of this complication remains unclear, as there is a sparsity of data published in the literature.
Use of temporary epicardial pacemaker wires to manage possible complications, as bradycardia, postoperative atrial fibrillation with need for cardiac defibrillation or atrioventricular block, is a common procedure in cardiac surgery . Although need of EPW can be questioned in selected cases, i.e. low-risk aortic valve replacement [6–8], presence of these wires can be very helpful in weaning from cardiopulmonary bypass or improving cardiac output in the early postoperative period .
At our department, EPW are sutured on the right atrium and right ventricle in every patient, except in presence of atrial fibrillation, where the atrial wire is omitted. We use a single type of temporary epicardial wires over the last years. Implantation of this type of wires does not necessitate any extra stitches.
The timing of EPW removal depends on the need for pacing postoperatively. These temporary wires are normally removed on the 4th to 5th POD by stable cardiac rhythm or later in cases where a cardioversion due to persistent postoperative atrial fibrillation is needed or a transient atrioventricular block demands pacing. Coagulation screening is made by every patient who is on VKA or high-dose unfractionated heparin before removing of these temporary wires, in order to prevent bleeding.
Several serious and somewhat bizarre complications after removal of EPW have been described in the literature [10–13]. Mahon et al. mention a less than 1% need for re-exploration due to pericardial tamponade after removal of EPW in a retrospective study involving more than 23000 patients with cardiac surgery . These data coincide with our findings, showing eight patients with pericardial tamponade, where removal of EPW was the definite cause of bleeding (incidence 0.18%). Defining removal of the EPW as the cause of bleeding was somewhat arduous as an active bleeding from the insertion site of the wires was found and needed to be surgically managed in only two of the eight patients. In the remaining six patients, echocardiography was normal before removal of the wires, whereas the clinical symptoms directly after taking out the wires were characteristic of a pericardial tamponade. Whether a late removal of the EPW can result in pericardial bleeding, it remains totally unclear.
Our patients were managed either with re-exploration through repeat sternotomy or with the insertion of a subxiphoid pericardial drainage. Unfortunately, the outcome was fatal in two cases (2 of 8), whereas need for blood transfusion and wound infection due to resternotomy complicated three of the remaining 6 patients. These data support the finding that pericardial tamponade after removal of the EPW increases both morbidity and mortality.
In addition, our database revealed six more cases with a late re-exploration after the 14 POD. All of these patients had been discharged from the hospital without any evidence of a significant pericardial effusion in the echocardiographic study, with the EPW being removed after echocardiography. Three of these patients, which were on VKA, had a documented serious derailment of INR during their rehabilitation. By the re-exploration of these patients, no definite cause of bleeding could be verified.
After studying of these data, we modified the standard procedure of removal of the EPW at our department. In order to minimize the risk of serious bleeding, we initiate the oral anticoagulation regimen – VKA or NOAC – after the EPW have been taken out. Although none of the eight patients were on NOACs, we believe that it is prudent to commence these regimens after pulling out the EPW, as no standard screening for NOACs is routinely used . On the other hand, patients who have a strong indication for DAPT, for example by coronary intervention with drug eluting stent implantation in the short-time perioperative period, still have their EPW removed under this medication. Whether it is rational to commence with the second antiplatelet agent after taking out the wires, it is dependent upon the indication for DAPT. Furthermore, we recommend that a high-dosed LMWH should be avoided 12 h before removal of EPW, and that intravenous administration of heparin should be paused for at least 3–4 h. Finally, performing the echocardiographic study after removal of the EPW, although a standard procedure by paediatric patients at our department is probably unrealistic as it is time-consuming and costly and even detection of some pericardial effusion may not prevent tamponade at a later time. Nevertheless, pre-removal echocardiography may detect a pericardial effusion that is clinically not apparent, but potentially aggravated by the EPW removal.
We conclude, that a serious bleeding necessitating re-exploration of a patient after removal of the EPW is a very rare complication (under 0.2%), which could probably be avoided or further minimized by adjusting the antiplatelet or anticoagulant medication in the postoperative period at the time of removal of the wires. This complication increases both morbidity and mortality. The need of temporary pacing after cardiac surgery, although debatable by some surgeons for selected cases, remains a standard at most departments.
Activated partial thromboplastin time
Coronary artery bypass grafting
Dual antiplatelet therapy
Epicardial pacemaker wires
International normalized ratio
Low molecular weight heparin
Novel oral anticoagulants
Vitamin K antagonist
Availability of data and materials
The authors do not wish to share these data. All data was obtained from the surgical database of our department (number of operations, type of procedures, etc.) and our findings are well described in the manuscript.
IB drafted the manuscript, IB, AL and MG collected the data, MF and TT analysed the data, FS gathered the literature, BD supervised the analysis and helped to draft the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
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