DDD Pacemaker Implantation After Fontan‐Type Operations

Abstract

Bradyarrhythmias developing after Fontan-type operations impair the function of the univentricular heart causing fatigue, headaches, ascites, and protein-losing enteropathy (PLE). Transvenous inaccessibility, requiring epicardial implantation, accounts for the reluctance to implant a pacemaker (PM). Between 1997 and 2000, 24 patients (mean age 9.5 years, range 6 months to 19 years) with Fontan-type operations received DDD pacing systems with atrial steroid-eluting stitch-on electrodes (mean capture threshold 1.9 V/0.5 ms, range 0.4-3.5 V) and ventricular screw-in electrodes (mean capture threshold 1.7 V/0.5 ms, range 0.1-3 V). The systems were implanted at the time of conversion from atrio- to cavopulmonary connections in 5 patients, at the time of a total cavopulmonary Fontan operation in 6, and 1-50 months thereafter (mean = 18) in 13 patients. A right ventricular anatomy was present in 13 (54%) of 24 of PM recipients, versus 35% of the overall population. After a mean follow-up of 3.5 years, the PM were functioning in DDD mode in 23 of the 24 patients. Length of hospital stay in the ten patients who underwent repeat sternotomy was 5 days, without procedure related complications. In three children a repeat sternotomy was avoided by implanting the atrial electrodes during the Fontan operation. All patients improved clinically, including resolution of PLE in four patients. Bradyarrhythmias may lead to significant morbidity after Fontan-type operations. Electrophysiological evaluation is advised at follow-up. The indication for implantation of a DDD pacemaker system should be liberal. Placing atrial electrodes during the Fontan operation, especially in the presence of a right ventricular anatomy, avoids repeat sternotomy.

Long-term atrial and ventricular epicardial pacemaker lead survival after cardiac operations in pediatric patients with congenital heart disease

“…2,4 This study establishes follow-up of epicardial leads up to 10 years in SV patients. In a report by Takahashi et al 23 describing the permanent atrial pacing lead implant route after the Fontan procedure, transvenous atrial pacing leads did not have an improved survival as compared with epicardial atrial leads.…”

“…2,3 Conversely, previous studies have demonstrated that epicardial leads have a higher fracture rate and higher pacing and lower sensing thresholds. 4,5 The epicardial approach is inherently invasive, potentially requiring a full or partial sternotomy or thoracotomy along with further surgical dissection to expose the atrium and ventricle. 6,7 In patients with prior cardiac surgery including those with complex CHD who underwent staged operations culminating in the Fontan procedure, the epicardium is often covered with scar tissue and adhesions that may result in higher pacing thresholds, potentially affecting lead performance.…”

Three-Dimensional Electroanatomic Voltage Map-Guided Treatment of a Patient with a Failing Atriopulmonary Fontan Circulation

“…To improve exercise capacity and functional status, dual-chamber pacing has been advocated for this patient population [4][5][6]11]. Transvenous atrial lead placement is often limited by increased atrial wall thickness and large areas of scarring.…”

Management of the Fontan circulation in the adult patient

“…(132,133) The majority of ventricular pacing is epicardial. (134,135) This requires at best a limited thorocotomy and may require full sternotomy and cardiopulmonary bypass, with the associated risks. In some patients access to the coronary sinus is possible via the Fontan circuit and in these "LV" leads have been placed with some success.…”