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To go left or right? Driving towards the best direction in paediatric pacing
Massimo Stefano Silvetti1, Luigina Porco1, Ilaria Tamburri1
1Paediatric Cardiology and Cardiac Arrhythmias Unit, Bambino Gesù Children's Hospital IRCCS, Piazza Sant'Onofrio 4, Rome00165, Italy.
Insights
Left ventricular apical epicardial pacing and right ventricular mid-septal pacing both preserve heart function in children with congenital complete atrioventricular block. These pacing methods show similar effectiveness in maintaining left ventricular contractility and synchrony.
Area of Science:
- Pediatric Cardiology
- Electrophysiology
- Cardiac Pacing
Background:
- Congenital complete atrioventricular block in children can lead to left ventricular dysfunction with permanent pacing.
- Alternative pacing sites, including left ventricular epicardial and right ventricular endocardial pacing, are explored to prevent this dysfunction.
Purpose of the Study:
- To compare left ventricular systolic function and synchrony between pediatric patients receiving left ventricular apical epicardial pacing versus right ventricular transvenous mid-septal pacing for congenital complete atrioventricular block.
Main Methods:
- A retrospective study comparing epicardial (surgical) and transvenous (3D electroanatomic mapping guided) pacing leads.
- Utilized ECG for QRS duration and echocardiography for synchrony (interventricular mechanical delay, septal to posterior wall motion delay, systolic dyssynchrony index) and contractility (global longitudinal strain, ejection fraction).
Main Results:
- Both pacing groups showed similar, preserved left ventricular ejection fraction and global longitudinal strain at 1 and 4 years.
- Synchrony parameters remained within normal limits for both left ventricular apical epicardial and right ventricular mid-septal pacing groups.
- Post-implantation QRS duration widened in both groups, but functional outcomes were comparable.
Conclusions:
- Left ventricular apical epicardial pacing and 3D mapping-guided right ventricular mid-septal pacing effectively preserve left ventricular contractility and synchrony in pediatric patients.
- No significant differences in functional outcomes were observed between the two pacing strategies at short- to mid-term follow-up.
Background:
Permanent pacing in children with isolated congenital complete atrioventricular block may cause left ventricular dysfunction. To prevent it, alternative pacing sites have been proposed: left ventricular epicardial or selective right ventricular endocardial pacing.
Aims:
To compare the functional outcome (left ventricular systolic function and synchrony) in paediatric patients with congenital complete atrioventricular block and left ventricular apical epicardial or right ventricular transvenous mid-septal pacing.
Methods:
Retrospective study. Epicardial leads were implanted by standard surgical technique, transvenous leads by 3D electroanatomic mapping systems. 3D mapping acquired 3D right ventricular local pacing map and defined the narrowest paced QRS site. 3D mapping guided screw-in bipolar leads on that ventricular site. Electrocardiogram (ECG) (QRS duration) and echocardiographic data (synchrony: interventricular mechanical delay, septal to posterior wall motion delay, systolic dyssynchrony index; contractility: global longitudinal strain, ejection fraction) were recorded. Data are reported as median [interquartile ranges]. p < 0.05 was significant.
Results:
There were 19 transvenous systems (age 8.8 [6-14] years; right ventricular mid-septum) and 17 epicardial systems (0.04 [0.001-0.6] years; left ventricular apex). Post-implantation QRS significantly widened either in endocardial or in epicardial patients. Most patients reached 4-year follow-up. One-year and 4-year ejection fraction and global longitudinal strain were mostly within normal limits and did not show significant differences between the two groups and between the same endocardial/epicardial group. Synchrony parameters were within normal limits in the two groups.
Conclusions:
Left ventricular apical epicardial pacing and 3D mapping-guided right ventricular mid-septal pacing preserved left ventricular contractility and synchrony in children and adolescents with congenital complete atrioventricular block at short-/mid-term follow-up, without relevant significant differences between the two groups.
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