Between January 1974 and November 1991 33 children received a permanent single- or dual-chamber pacing system, mainly because of postoperative high-degree AV block. The children were followed up retrospectively for pacemaker- and lead-related complications, and for differences between epi- and endocardial stimulation. The overall rate of lead related complications was 35% and did not differ significantly between the epi- and endocardially paced groups, although it tended to be somewhat higher in the epicardially paced children, mainly due to a higher rate of exit blocks in the latter. The epicardially stimulated patients exhibited a significantly higher rate of pacemaker-related complications, which was primarily accounted for by a higher frequency of battery depletions in the epicardial systems. The most impressive differences between both groups, however, was seen with respect to subacute and chronic energy consumption. Chronic energy drain in the epicardially paced patients amounted to almost the sixfold of that seen in the endocardially stimulated children. This resulted in a significantly shorter cumulative pacemaker survival in the epicardial group. Therefore, it is concluded that, whenever possible, the transvenous approach be used in children and small infants too. However, as a rule, in the latter transvenous dualchamber pacing is usually not feasible. In these cases rate-adaptive single-chamber pacing has evolved as a reasonable alternative for improving hemodynamics as well as quality of life. In epicardial pacing the use of pulse generators allowing bidirectional telemetry is advisable. In this way monitoring of lead impedance and battery status can be performed noninvasively, thus permitting individualization of pulse widths and amplitude setting, which is important with respect to energy conservation.
N 8-YEAR-OLD GIRL PRESENTED AT OUR INSTITUtion with a 6 month history of increasing peripheral oedema, ascites, hepatosplenomegaly, and biopsy-proven hepatic cirrhosis of unknown aetiology. Transthoracic echocardiography revealed leftward deviation of the atrial septum, and dilation of the caval veins. Flow from the caval veins was restricted by a single opening in a shelf separating an anterior, supratricuspid, component of the right atrium from a posterior systemic venous sinus to which the caval veins connected (Fig. 1). The mean pressure gradient between the two atrial components, estimated by pulse wave Doppler, was 20 mmHg. Transoesophageal echocardiography confirmed the diagnosis of divided right atrium (Fig. 2;
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