Problems with Permanent Atrial Pacing in the Fontan Patient

Abstract

Transvenous atrial pacing is the preferred method for control of both brady and tachyarrhythmias in the postoperative pediatric patient with normal atrioventricular conduction. We reviewed our experience with the use of permanent atrial pacing for the control of bradycardia and tachycardia in the Fontan patient. We then compared this pacing experience to atrial pacing data compiled for postop Transposition of the Great Arteries (TGA) patients. Out of twenty‐five Fontan patients followed at the Medical University of South Carolina, six patients have had atrial arrhythmias necessitating pacing (24%). Underlying congenital heart disease included tricuspid atresia physiology in three and single ventricle in three. The indications for atrial pacing was brady‐tachy syndrome in four patients and sick sinus syndrome in two. Pacers were inserted immediately postop in three patients and 1.5 years, 2 years, and 8 years post Fontan in the other three. These six patients have required a total of nine pulse generator implantations. Five of the nine pacers were inserted transvenously and four via thoracotomy. In contrast to our experience with permanent atrial pacing in post TGA patients, dysrhythmia control with atrial pacing in the Fontan patient has been more difficult to achieve. The Fontan patients have a higher incidence of symptomatic dysrhythmias, hospitalizations, and antidysrhythmic medication requirements after pacer insertion. Implantation thresholds of the Fontan patients are higher than those of the transposition group. While successful atrial demand pacing is attainable in both groups, antitachycardia pacing is more reliable in the postop TGA patient. The Fontan procedure seems to present a new set of obstacles for successful atrial pacing in the pediatric postop patient.

Novel Approach to Transvenous Pacemaker Implantation in a Post-Fontan Adolescent

“…Individual patient characteristics influence the choice between epicardial and transvenous atrial pacing. The Fontan procedure per se eliminates the potential for transvenous ventricular pacing except when an atrioventricular conduit is part of the repair [1]. Other Fontan modifications designed to accommodate associated heart defects and improve postoperative hemodynamics may impede access to the atrium for transvenous pacing.…”

“…Extensive atrial surgery involving placement of intraatrial baffles in patients undergoing repair of congenital heart lesions (e.g., Fontan procedure for functional single ventricle) contribute to subsequent sinus node dysfunc- tion, AV block, and supraventricular tachyarrhythmias in many patients [1,3,5,6]. Some patients require pacemaker implantation for bradycardia support with or without concomitant antiarrhythmic agents or antitachycardia pacing.…”

“…Cavopulmonary and atriopulmonary connections are important Fontan modifications that extend the number of patients able to undergo this repair [2]. Regardless of the type of Fontan procedure, these patients may develop postoperative sinus bradycardia, supraventricular tachyarrhythmias, or advanced or complete atrioventricular (AV) block [1,3,5,6]. Patient management may include administration of antiarrhythmic agents to reduce the frequency and severity of episodes of tachycardia, permanent cardiac pacing for bradycardia support, and antitachycardia pacing [1, 3, 6].…”

The combined use of amiodarone and class 1-C antiarrhythmic agents in children with intractable supraventricular tachyarrhythmias

“…The child with atrial flutter after a Fontan operation presents difficult clinical problems. The arrhythmia is often resistant to most antiarrhythmic drugs, 16 may not respond to anti-tachycardia pacing, 16 and may predispose to sudden death. 17 In such patients a high risk strategy is often justified.…”

Endocardial transvenous pacing in patients with surgically palliated univentricular hearts: A review on different techniques, problems and management

“…Heterotaxy syndromes, atrioventricular discordance, single ventricles are more often associated with these rhythm disorders than others. Pacemaker implantation is the commonest reintervention following Fontan surgery due to sinus node dysfunction in 9–23% of patients and atrioventricular nodal conduction abnormalities in 2–16% of patients [[1], [2], [3]]. Atrioventricular nodal block may occur either spontaneously in the natural history of few univentricular hearts or follow treatment of atrial tachyarrhythmia.…”