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Permanent cardiac pacing after the Fontan procedure
Insights
Permanent cardiac pacing after a Fontan procedure is complex. This study evaluated 15 patients, finding that epicardial ventricular leads and programmable pulse generators are key for successful pacing outcomes in this population.
Area of Science:
- Cardiology
- Pediatric Cardiology
- Cardiac Electrophysiology
Background:
- The Fontan procedure creates complex cardiovascular anatomy, often necessitating permanent cardiac pacing postoperatively.
- Congenital heart defects and surgical interventions can lead to heart block or sick sinus syndrome, requiring pacing solutions.
Purpose of the Study:
- To evaluate the outcomes and current approach to permanent cardiac pacing in patients who have undergone a Fontan procedure.
- To identify challenges and effective strategies for pacemaker implantation in this complex patient group.
Main Methods:
- Retrospective review of 15 patients requiring permanent pacing after Fontan procedure at Mayo Clinic.
- Analysis of patient demographics, underlying cardiac defects, indications for pacing, pacemaker systems, lead types, and follow-up data.
- Description of the current institutional approach to pacing post-Fontan.
Main Results:
- Fifteen patients (mean age 16.5 years) required permanent pacing due to heart block or sick sinus syndrome.
- Epicardial ventricular leads were universally used; atrial leads were transvenous or epicardial.
- Three patients died from unrelated causes; survivors experienced minimal pacing complications, primarily loss of ventricular capture due to elevated thresholds.
Conclusions:
- Permanent pacing after Fontan procedure is feasible and can be managed effectively with specific strategies.
- Intraoperative placement of epicardial ventricular leads and use of programmable pulse generators with high output are crucial.
- A systematic approach involving temporary and permanent leads, tailored to individual needs, optimizes pacing outcomes in Fontan patients.
Abstract:
Permanent cardiac pacing after a Fontan procedure is complicated by complex cardiovascular anatomy. Of 332 patients undergoing the Fontan procedure at the Mayo Clinic, we evaluated 15 who postoperatively required permanent pacing (mean age 16.5 years, range 4 to 31 years). Underlying congenital cardiac defects included univentricular heart in nine patients, double-outlet right ventricle in three, and tricuspid atresia in three. The indication for pacing was postoperative heart block in seven patients, congenital heart block in five, postoperative sick sinus syndrome in two, and heart block because of previous operation in one. Pacemakers were implanted immediately postoperatively in 11 patients and 12 to 57 months later in four patients. VVI systems were used in nine patients, DDD in four, AAI in one, and a Medtronic Activitrax VVI in one. All ventricular leads were epicardial. Four atrial leads were transvenous endocardial and one was epicardial. Three patients died 4, 9, and 69 months later of causes unrelated to pacing. Among the 12 survivors, mean follow-up was 34 months (range 1 to 107 months). Two patients had a total of three episodes of loss of ventricular capture because of increased chronic thresholds. Our current approach to pacing after a Fontan procedure includes (1) intraoperative placement of temporary atrial and ventricular electrodes, (2) intraoperative attachment of a permanent ventricular epicardial lead for congenital or surgically induced high-grade atrioventricular block, (3) postoperative insertion of transvenous atrial leads if dual-chamber pacing is indicated, and (4) use of programmable pulse generators with high output capability.