Transvenous Versus Epicardial Pacing in Fontan Patients

Permanent Cardiac Pacing in the Fontan Population: A Contemporary Review of Indications, Approaches, and Outcomes

Following the Fontan operation, electrophysiologic abnormalities requiring pacemaker implantation are common, consisting of sinus node dysfunction, complete atrioventricular block, and electromechanical dyssynchrony. Pacemaker implantation in this population can be challenging, as transvenous access to the cardiac chambers is often limited and may increase the risk of thromboembolism. Consequently, epicardial lead placement continues to be the default approach at most centers. Furthermore, permanent cardiac pacing has been associated with poor outcomes in this population (including an increased need for cardiac transplantation and death), even though it may be, depending on the approach, of great benefit for many individuals. Fortunately, improved understanding of the differential effects of cardiac pacing and novel approaches related to implantation have been developed and have increased their application to a growing number of patients. This review highlights the indications for pacing, methods to facilitate lead implantation, and associated outcomes in Fontan patients requiring permanent cardiac pacing.

Brady-arrhythmias requiring permanent pacemaker implantation during and after staged Fontan palliation

BACKGROUND

Brady-arrhythmia requiring pacemaker implantation remains one of the Fontan-specific complications before and after total cavopulmonary connection.

METHODS

A retrospective analysis of 620 patients who underwent total cavopulmonary connection between 1994 and 2021 was performed to evaluate the incidence of brady-arrhythmia and the outcomes after pacemaker implantation. Factors associated with the onset of brady-arrhythmia were identified.

RESULTS

A total of 52 patients presented with brady-arrhythmia and required pacemaker implantation. Diagnosis included 16 sinus node dysfunctions, 29 atrioventricular blocks, and 7 junctional escape rhythms. Pacemaker implantation was performed before total cavopulmonary connection (n = 16), concomitant with total cavopulmonary connection (n = 8), or after total cavopulmonary connection (n = 28, median 1.8 years post-operatively). Freedom from pacemaker implantation following total cavopulmonary connection at 10 years was 92%. Twelve patients needed revision of electrodes due to lead dysfunction (n = 9), infections (n = 2), or dislocation (n = 1). Lead energy thresholds were stable, and freedom from pacemaker lead revision at 10 years after total cavopulmonary connection was 78%. Congenitally corrected transposition of the great arteries (odds ratio: 6.6, confidence interval: 2.0-21.5, p = 0.002) was identified as a factor associated with pacemaker implantation before total cavopulmonary connection. Pacemaker rhythms for Fontan circulation were not a risk factor for survival (p = 0.226), protein-losing enteropathy/plastic bronchitis (p = 0.973), or thromboembolic complications (p = 0.424).

CONCLUSIONS

In our cohort of patients following total cavopulmonary connection, freedom from pacemaker implantation at 10 years was 92% and stable atrial and ventricular lead energy thresholds were observed. Congenitally corrected transposition of the great arteries was at increased risk for pacemaker implantation before total cavopulmonary connection. Having a pacemaker in the Fontan circulation had no adverse effect on survival, protein-losing enteropathy/plastic bronchitis, or thromboembolic complications.

Epicardial Versus Endocardial Pacing in Paediatric Patients with Atrioventricular Block or Sinus Node Dysfunction: A Systematic Review and Meta-analysis

Pacing indications in children are clearly defined, but whether an epicardial (EPI) or an endocardial (ENDO) pacemaker performs better remains to be elucidated. This systematic review and meta-analysis aimed to directly compare the incidence of pacemaker (PM) lead-related complications, mortality, hemothorax and venous occlusion between EPI and ENDO in children with atrioventricular block (AVB) or sinus node dysfunction (SND). Literature search was conducted in MEDLINE (via PubMed), Scopus by ELSEVIER, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and OpenGrey databases until June 25, 2022. Random-effects meta-analyses were performed to assess the pacing method's effect on lead failure, threshold rise, post-implantation infection and battery depletion and secondarily on all-cause mortality, hemothorax and venous occlusion. Several sensitivity analyses were also performed. Of 22 studies initially retrieved, 18 were deemed eligible for systematic review and 15 for meta-analysis. Of 1348 pediatric patients that underwent EPI or ENDO implantation, 542 (40.2%) had a diagnosis of congenital heart disease (CHD). EPI was significantly associated with higher possibility of PM-lead failure [pooled odds ratio (pOR) 3.00, 95% confidence interval (CI) 2.05-4.39; I2 = 0%]; while possibility for threshold rise, post-implantation infection and battery depletion did not differ between the PM types. Regarding the secondary outcome, the mortality rates between EPI and ENDO did not differ. In sensitivity analyses the results were consistent results between the two PM types. The findings suggest that EPI may be associated with increased PM-lead failure compared to ENDO while threshold rise, infection, battery depletion and mortality rates did not differ.

Impact and Modifiers of Ventricular Pacing in Patients With Single Ventricle Circulation

BACKGROUND

Palliation of the single ventricle (SV) circulation is associated with a burden of lifelong complications. Previous studies have identified that the need for a permanent ventricular pacing system (PPM_v) may be associated with additional adverse long-term outcomes.

OBJECTIVES

The goal of this study was to quantify the attributable risk of PPM_v in patients with SV, and to identify modifiable risk factors.

METHODS

This international study was sponsored by the Pediatric and Congenital Electrophysiology Society. Centers contributed baseline and longitudinal data for functionally SV patients with PPM_v. Enrollment was at implantation. Controls were matched 1:1 to PPM_v subjects by ventricular morphology and sex, identified within center, and enrolled at matched age. Primary outcome was transplantation or death.

RESULTS

In total, 236 PPM_v subjects and 213 matched controls were identified (22 centers, 9 countries). Median age at enrollment was 5.3 years (quartiles: 1.5-13.2 years), follow-up 6.9 years (3.4-11.6 years). Median percent ventricular pacing (Vp) was 90.8% (25th-75th percentile: 4.3%-100%) in the PPM_v cohort. Across 213 matched pairs, multivariable HR for death/transplant associated with PPM_v was 3.8 (95% CI 1.9-7.6; P < 0.001). Within the PPM_v population, higher Vp (HR: 1.009 per %; P = 0.009), higher QRS z-score (HR: 1.19; P = 0.009) and nonapical lead position (HR: 2.17; P = 0.042) were all associated with death/transplantation.

CONCLUSIONS

PPM_v in patients with SV is associated with increased risk of heart transplantation and death, despite controlling for increased associated morbidity of the PPM_v cohort. Increased Vp, higher QRS z-score, and nonapical ventricular lead position are all associated with higher risk of adverse outcome and may be modifiable risk factors.

VDI pacing with temporary esophageal and transvenous pacemaker leads to treat post-cardiac surgery cardiogenic shock

Background

Post-operative atrio-ventricular (AV) block after cardiac surgery is not uncommon in high-risk patients.

Case presentation

Our case highlights the management of a 62-year-old female with cardiogenic shock post-cardiac surgery with concomitant complete heart block. With VVI pacing proving ineffective, it was postulated that the patient may benefit hemodynamically from AV sequential pacing, re-establishing her atrial kick. We describe a novel technique of attaching a temporary pacemaker wire to an orogastric tube to sense atrial p-waves and pace the ventricle transvenously to perform AV sequential pacing. This was done temporarily to stabilize the patient’s hemodynamic status while awaiting a permanent pacemaker implantation.

Conclusions

In hemodynamically unstable post-cardiac surgery patients with complete heart block in whom VVI pacing fails to improve their clinical status, clinicians should consider VDI pacing with an orogastric atrial sensing pacemaker lead, in consultation with the cardiac surgeon and the electrophysiology team. Of note, the patient needs to have underlying organized atrial activity for this setup to work.

Pacemaker implantation via femoral vein and successful arrhythmia management in an elderly patient with Fontan circulation: a case report

Background

The frequency of arrhythmias increases after the Fontan operation over time; atrial tachycardia (AT) and sinus node dysfunction (SND) are frequently observed.

Case summary

Our patient was 63-year-old woman who underwent a lateral tunnel Fontan operation for double outlet right ventricle at age 36. She experienced paroxysmal AT for 1 year, and antiarrhythmic medication was not feasible due to symptomatic SND. Computed tomography revealed a 45 mm-sized thrombus in the high right atrium (RA). The patient had three coexisting conditions: paroxysmal AT, symptomatic SND, and the right atrial thrombus, for which total cavopulmonary connection conversion and epicardial pacemaker implantation (PMI) would have been effective; however, given her age and comorbidities, surgical treatment was considered high risk. Catheter ablation was avoided because of the right atrial thrombus. Finally, a transvenous pacemaker was implanted via the right femoral vein to avoid the right atrial thrombus and severe venous tortuosity from the left subclavian vein to the RA. After PMI, the patient was prescribed amiodarone and bisoprolol for AT suppression. Atrial tachycardia occurred once in the third month after discharge. We increased the dose of amiodarone, and she has been tachycardia-free.

Discussion

Transvenous PMI must be considered in cases where open thoracic surgery or catheter ablation cannot be performed. This is the first report of transvenous PMI via the right femoral vein and successful AT and SND management in an elderly Fontan patient.

Original Article--Outcomes of Pacing in Egyptian Pediatric Population

Objectives

Permanent pacemakers are widely used in the pediatric population due to congenital and surgically acquired rhythm disturbances. The diversity and complexity of congenital heart diseases make device management a highly individualized procedure in pediatric pacing. We are also faced with special problems in pediatric age group as growth, children’s activity and infection susceptibility. This study aimed to present our institute’s experience in pediatric and adolescent pacemaker implantation and long-term outcomes.

Methods

This cross-sectional observational study included 100 pediatric patients who visited our outpatient clinics at Ain Shams University Hospitals for regular follow up of their previously implanted permanent pacemakers. All patients were subjected to history taking, clinical examination, ECG recording, echocardiography and elaborate device programming. Data about device types, device components’ longevity, subsequent procedures, complications were collected, with comparison between epicardial and endocardial pacemakers.

Results

Our study population ranged in age from 8 months to 18 years (mean 13.12 ± 5.04 years), 51 were males and 53 patients had congenital heart disease. Epicardial pacing represented 26% of our total population using only VVIR pacemakers, while endocardial pacing represented 74% of our population with 58.1% of them being VVIR pacemakers. First battery longevity was higher in endocardial batteries (108 months vs. 60 months, p value: 0.007). First lead longevity was also higher in endocardial leads (105 moths vs. 58 months, p value: 0.006). Complication rate was 25%; 8 patients had early complications (one insulation break in endocardial group). Late complications occurred in 17 patients (10 patients had lead fracture; 9 of them were endocardial, 2 insulation breaks in endocardial leads, 3 patients from epicardial group had lead failure of capture). In total, 16 patients had lead-related complications. There was no statistically significant difference between different lead models regarding lead-related complications.

Conclusion

Pacemakers in children are generally safe, but still having high rates of lead-related complications. Lead failure of capture was more common in epicardial leads. These complications had no relation to the model of the leads. Endocardial pacemakers showed higher first lead and first battery longevity compared to epicardial pacemakers.