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In 1977, a 30 month old female child with congenital complete heart block and recurrent Stokes Adams attacks underwent single chamber (VVI) permanent pacemaker implantation in the anterior abdominal wall with tunnelled epicardial pacing lead. Due to local infection the pacing system had to be removed and the lead cut (abdominal lead 3, panel A). The next site chosen for placement of the generator (PM-2) was intrathoracic, in the left retropleural space by lateral thoracotomy. During the placement of this left ventricular epicardial lead (lead 1), the cardiac end of the initial lead had been cut close to the heart (thoracic lead 3). After 14 years, the same author placed a transvenous single pacing system (PM-2) with endocardial right ventricular lead (lead 2). Panel B shows the chest x ray in postero-anterior (PA) view. Now aged 28 years, the patient is married with two healthy children who were delivered uneventfully. Generator change for battery depletion is due in six months.
Pacing in infancy and childhood was a challenging task in the 1960s and ’70s. Large generators (weighing about 200 g), a greater risk of perforation and secondary infection, frequent generator replacement due to short battery life, and the growth of the child which could dislodge lead systems and alter pacing parameters, were only a few of the issues that had to be tackled. Due to lack of space in the subcutaneous tissue of the chest wall, generators were implanted surgically in the abdomen or retropleural space. Newer pacing techniques and the reduction in generator size (to about 20 g) has resulted in much easier and safer pacing outcomes today.