Long-term transvenous AV-sequential pacing in a failing atriopulmonary Fontan patient

We report on a 32-year-old man with tricuspid atresia, pulmonary stenosis and hypoplastic right ventricle. He had received a Fontan-Kreutzer procedure (anastomosis between the right atrial appendage and the pulmonary artery) at the age of 14 years. At the age of 2 years, an abdominal VVI-pacemaker with an epicardial ventricular lead had been implanted because of symptomatic third degree AV-block. The patient was now hospitalized with symptoms of severe congestive heart failure. A least invasive approach restoration of AV-synchrony by a dual chamber pacer was performed. Therefore a complete transvenous approach to avoid thoracotomy was attempted. A specially designed CS lead was advanced via the CS to a left lateral ventricular vein for ventricular stimulation. After institution of dual chamber pacing the patient recovered of his heart failure. During a follow-up time of 20 months the patient was clinically stable in the AV-sequential pacing.

Dual chamber pacing using a transvenously placed coronary sinus lead for ventricular stimulation may improve congestive heart failure in patients after the classic Fontan operation. The minimally invasive transvenous approach might be the best solution for patients who need a pacemaker and are not candidates for surgery or heart transplantation.