Endocardial Atrial Pacing Lead Implantation and Midterm Follow‐Up in Young Patients with Sinus Node Dysfunction After the Fontan Procedure

Abstract

The purpose of the study was to investigate the results of endocardial lead implantation, lead performance, and follow-up in young patients after the Fontan procedure. A retrospective study was conducted with patients who had endocardial atrial pacing for SND and intact AVN function after Fontan from two pediatric centers. Patient demographics, pacing, and sensing data of endocardial atrial leads were analyzed at the time of pacemaker implantation and follow-up visits. Fifteen patients (weight 42.6 +/- 35 kg) had transvenous endocardial atrial lead implantation at an average age of 11.4 +/- 6.5 years. Active-fixation leads were used in all patients and steroid elution was present in 12 (80%) patients. Adequate P wave sensing was obtained in patients with sinus rhythm (n = 10); the remaining four patients had junctional rhythm without measurable P waves. Lead failure was not observed in any patient during the follow-up period of 2.9 +/- 2.1 years. The energy threshold at implantation was 1.46 +/- 1.5 microJ, 1.54 +/- 0.75 microJ at 3 months, 0.62 +/- 0.45 microJ at 1 year, 0.72 +/- 0.65 microJ at 2 years, 0.75 +/- 0.55 microJ at 3 years, and 0.8 +/- 0.85 microJ at 5 years postimplant. The lead impedance was 648 +/- 298 omega at implantation, 714 +/- 163 omega at 3 months, 744 +/- 195 omega at 1 year, 734 +/- 198 omega at 2 years, 800 +/- 142 omega at 3 years and 830 +/- 200 omega 5 years postimplant. Anticoagulation therapy (aspirin n = 5, warfarin n = 8) was continued by 13 patients. Complications consisted of a pneumothorax at implantation and a transient ischemic attack in one patient 4 years after pacemaker implant. Endocardial atrial leads offer low energy thresholds and can be implanted relatively safely in Fontan patients.

The Spectrum of Long-term Electrophysiologic Abnormalities in Patients with Univentricular Hearts

“…A transvenous pacemaker approach has been utilized in a small number of patients with good short‐term follow‐up 25–27 . The major concern for the transvenous approach is the potential for clots to form around the pacing lead.…”

Interventional Electrophysiology in Patients With Congenital Heart Disease

“…Transvenous ventricular pacing can sometimes be accomplished with a lead advanced into a ventricular branch off the coronary sinus in patients with the old variety of atriopulmonary Fontan anastomosis, but this option is not available for those with modern cavopulmonary connections. 95,96 The venous route to the atrium and ventricle in Mustard or Senning patients is likewise challenging. Transvenous leads need to be advanced through the atrial baffle before fixation in the modified right atrium and the anatomic left ventricle, and it is not uncommon to encounter tight obstruction along the upper limb of the baffle that requires dilation and stent placement before leads can be passed.…”

Transvenous Atrial Pacing from the Superior Vena Cava Stump after the Hemi‐Fontan Operation—A New Approach

“…Thirteen were anticoagulated or on antiplatelet medication. One of the two patients who were not on any anticoagulation or antiplatelet therapy had a transient ischemic attack during midterm follow‐up, which was felt to be related to a right to left shunt . Hansky et al reported seven patients after endocardial atrial pacing after the Fontan operation.…”