Transvenous pacing in pediatric patients☆

The permanent cardiac pacing in children constitutes an important challenge for paediatric cardiologist and for surgeons performing implantation procedures. This task involves not only a necessity for establishing indications but also a need for a specific selection of the pacing leads and pacemaker, and the implantation technique. The number of paediatric patients who need a pacemaker implantation is increasing, including not only patients with congenital atrioventricular conduction disorders and fewer cases of sick sinus syndrome but also the patients after congenital heart diseases surgery. The main concept in electrotherapy in children remains the same as in adults: the prevention of a significant symptomatic bradycardia as well as the provision of an undisturbed physical growth and intellectual development. A physician responsible for therapeutic decision-making should be aware of life-long consequences in this age group, where pacing will be continued usually for several decades.

The authors of this paper discuss the indications for pacing and pacing modes in children and adolescents and in patients with congenital heart defects, based mainly on the current electrotherapy guidelines and specific age-related modifications. The knowledge of these problems will help in a safe, quick and proper implementation of this kind of therapy, to prevent sudden cardiac death, to improve quality of life and the children's development.

Intravenous pacemaker lead implantation for small children is not performed routinely. Here, we report the case of a pediatric patient who underwent endocardial lead implantation and follow-up for 16 years. The patient was a 4-year-old boy who underwent total correction of pulmonary atresia with ventricular septal defect following several palliative operations. After the patient underwent total correction, atrial flutter was noted. Atrial flutter was successfully terminated by overdrive pacing. However, atrial flutter occurred again immediately after overdrive pacing. To treat atrial flutter caused by sick sinus syndrome, a screw-in type lead was attached to the free wall of the right atrium and an excess loop was left to allow for the patient's growth. During the 16-year follow-up, no adverse effects were observed except for a gradual increase in pacing threshold. The selection of a small-sized endocardial lead and an appropriate entry vein, with meticulous management of the leads, makes implantation of an endocardial lead for small children easier and safer.

Despite pacemaker therapy in children and adolescents favoring an initial epicardial approach, predictors of lead failure have not been well clarified. The aim of this study was to assess the long-term outcomes and to determine predictors affecting lead durability in pediatric pacing therapy.

We reviewed the outcomes of 109 consecutive pacing leads implanted in 55 patients (median age, 5.2 years; range, 31 days–15.8 years), including 38 atrial and 71 ventricular leads. They consisted of 58 (53%) fishhooks, 37 (34%) screw-in leads, and 14 (13%) steroid-eluting suture-on leads. Seventy (64%) were implanted in patients with structural heart disease.

The leads were followed for a median of 6.4 years (range, 3 days–22.9 years). Lead failure occurred in 29 leads (27%; median of 8.4 years after implantation). Exit block or elevation of pacing threshold was the most common cause (n = 18), but failures did not directly cause patient death. The overall 1-, 5-, 10-, and 15-year lead survivals were 100%, 89.0%, 72.5%, and 55.5%, respectively. Multivariate Cox analysis revealed concurrent structural heart disease (relative risk, 2.85; 95% confidence interval, 1.27–6.42; P = .011) to be the only significant predictor of lead failure.

Epicardial leads provide a reliable technique for managing rhythmic disturbance problems in the pediatric population. The only significant predictor of lead failure is the presence of structural heart disease.