Surgical management of difficult pacing problems in patients with congenital heart disease

The child with congenital heart disease requiring permanent pacing presents a unique challenge with regard to the decision to pace, hardware, route, and unusual problems. Considerations of patient size, anatomy, insertion during and after complex intracardiac procedures, location of hardware, and unusual approaches are discussed including: placement of endocardial leads at open operation, closed transatrial endocardial technique, periprosthetic valvular endocardial placement, trans left superior vena cava placement and retromammary position via the axillary approach. Consideration of these unusual techniques may avoid frustration due to the complexities of the placement of pacing systems in these young patients.