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Shin H, Baek JS, Kim MJ, Cha S, Yu JJ. Pacemaker-Related Factors and Outcomes of Fontan Patients - Impact of Paced QRS Duration. Circ J 2024; 88:642-648. [PMID: 38267052 DOI: 10.1253/circj.cj-23-0491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
BACKGROUND Permanent pacemaker (PPM) implantation has been identified as a risk factor for morbidity and mortality after Fontan operation. This study investigated the factors associated with outcomes in patients with Fontan physiology who underwent PPM implantation. METHODS AND RESULTS We retrospectively reviewed 508 patients who underwent Fontan surgery at Asan Medical Center between September 1992 and August 2022. Of these patients, 37 (7.3%) received PPM implantation. Five patients were excluded, leaving 32 patients, of whom 11 were categorized into the poor outcome group. Poor outcomes comprised death, heart transplantation, and "Fontan failure". Clinical, Fontan procedure-related, and PPM-related factors were compared between the poor and good outcome groups. Ventricular morphology, Fontan procedure-associated factors, pacing mode, high ventricular pacing rate, and time from first arrhythmia to PPM implantation did not differ significantly between the 2 groups. However, the poor outcome group exhibited a significantly longer mean paced QRS duration (P=0.044). Receiver operating characteristic curve analysis revealed a paced QRS duration cut-off value of 153 ms with an area under the curve of 0.73 (P=0.035). CONCLUSIONS A longer paced QRS duration was associated with poor outcomes, indicating its potential to predict adverse outcomes among Fontan patients.
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Affiliation(s)
- Hyewon Shin
- Division of Pediatric Cardiology, Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine
| | - Jae Suk Baek
- Division of Pediatric Cardiology, Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine
| | - Mi Jin Kim
- Division of Pediatric Cardiology, Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine
| | - Seulgi Cha
- Division of Pediatric Cardiology, Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine
| | - Jeong Jin Yu
- Division of Pediatric Cardiology, Department of Pediatrics, Asan Medical Center Children's Hospital, Ulsan University College of Medicine
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2
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Bohn C, Schaeffer T, Staehler H, Heinisch PP, Piber N, Cuman M, Hager A, Ewert P, Hörer J, Ono M. Brady-arrhythmias requiring permanent pacemaker implantation during and after staged Fontan palliation. Cardiol Young 2024; 34:524-530. [PMID: 37496165 DOI: 10.1017/s1047951123002500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
BACKGROUND Brady-arrhythmia requiring pacemaker implantation remains one of the Fontan-specific complications before and after total cavopulmonary connection. METHODS A retrospective analysis of 620 patients who underwent total cavopulmonary connection between 1994 and 2021 was performed to evaluate the incidence of brady-arrhythmia and the outcomes after pacemaker implantation. Factors associated with the onset of brady-arrhythmia were identified. RESULTS A total of 52 patients presented with brady-arrhythmia and required pacemaker implantation. Diagnosis included 16 sinus node dysfunctions, 29 atrioventricular blocks, and 7 junctional escape rhythms. Pacemaker implantation was performed before total cavopulmonary connection (n = 16), concomitant with total cavopulmonary connection (n = 8), or after total cavopulmonary connection (n = 28, median 1.8 years post-operatively). Freedom from pacemaker implantation following total cavopulmonary connection at 10 years was 92%. Twelve patients needed revision of electrodes due to lead dysfunction (n = 9), infections (n = 2), or dislocation (n = 1). Lead energy thresholds were stable, and freedom from pacemaker lead revision at 10 years after total cavopulmonary connection was 78%. Congenitally corrected transposition of the great arteries (odds ratio: 6.6, confidence interval: 2.0-21.5, p = 0.002) was identified as a factor associated with pacemaker implantation before total cavopulmonary connection. Pacemaker rhythms for Fontan circulation were not a risk factor for survival (p = 0.226), protein-losing enteropathy/plastic bronchitis (p = 0.973), or thromboembolic complications (p = 0.424). CONCLUSIONS In our cohort of patients following total cavopulmonary connection, freedom from pacemaker implantation at 10 years was 92% and stable atrial and ventricular lead energy thresholds were observed. Congenitally corrected transposition of the great arteries was at increased risk for pacemaker implantation before total cavopulmonary connection. Having a pacemaker in the Fontan circulation had no adverse effect on survival, protein-losing enteropathy/plastic bronchitis, or thromboembolic complications.
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Affiliation(s)
- Cornelius Bohn
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität, Munich, Germany
- University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Thibault Schaeffer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität, Munich, Germany
- University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Helena Staehler
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität, Munich, Germany
- University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Paul Philipp Heinisch
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität, Munich, Germany
- University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Nicole Piber
- Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Magdalena Cuman
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Alfred Hager
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Peter Ewert
- Department of Congenital Heart Disease and Pediatric Cardiology, German Heart Center Munich, Technische Universität München, Munich, Germany
| | - Jürgen Hörer
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität, Munich, Germany
- University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
| | - Masamichi Ono
- Department of Congenital and Pediatric Heart Surgery, German Heart Center Munich, Technische Universität, Munich, Germany
- University Hospital of Munich, Ludwig-Maximilians-Universität, Munich, Germany
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3
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Yang EL, Evers PD, Long MJ, Mostafavifar M, Balaji S. Impact of Atrial Pacing in Fontan Patients with Junctional Rhythm: A Prospective Echocardiographic Study. Pediatr Cardiol 2024; 45:361-367. [PMID: 38062259 DOI: 10.1007/s00246-023-03345-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 11/03/2023] [Indexed: 01/28/2024]
Abstract
Sinus node dysfunction (SND) with junctional rhythm (JR) is common after the Fontan operation. Atrial pacing (AP) restores atrioventricular (AV) synchrony, but the placement of a pacemaker carries significant morbidity. To study the impact of AP on echocardiographic parameters of function in Fontan patients with SND and JR. Nine Fontan patients with AP for SND and JR were prospectively studied with echocardiography in the following conditions-baseline paced rhythm, underlying JR and, if possible, slow-paced rhythm below their baseline paced rate (~ 10 bpm faster than their JR rate). Cardiac index was significantly lower in JR (3 ± 1.1 L/min/m2) vs AP (4.2 ± 1.4 L/min/m2; p = 0.002). Diastolic function also significantly worsened with increased ratio of early diastolic systemic AV valve inflow velocity to early diastolic systemic AV valve annulus velocity (E/e' ratio) by tissue Doppler imaging (TDI) in JR (11.6 ± 4.6) vs AP (8.8 ± 2.2, p = 0.016). Pulmonary venous flow reversal was present in 7/9 patients in JR vs 0/9 in AP (p = 0.016). There were no significant differences in these echocardiographic measurements between the paced and slow-paced conditions. When compared to AP, JR was associated with a significant reduction in cardiac output and diastolic function, and an increased prevalence of pulmonary vein flow reversal. There were no differences between paced and slow-paced conditions, suggesting that AV synchrony rather than heart rate was primarily contributing to cardiac output. Further studies are needed to understand the chronic impact of JR on Fontan outcomes.
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Affiliation(s)
- Emily L Yang
- Division of Pediatric Cardiology, Oregon Health and Science University, 707 SW Gaines Street, Mail code: CDRC-P, Portland, OR, 97239, USA.
| | - Patrick D Evers
- Division of Pediatric Cardiology, Oregon Health and Science University, 707 SW Gaines Street, Mail code: CDRC-P, Portland, OR, 97239, USA
| | - Mia J Long
- Division of Pediatric Cardiology, Oregon Health and Science University, 707 SW Gaines Street, Mail code: CDRC-P, Portland, OR, 97239, USA
| | - Mina Mostafavifar
- Division of Pediatric Cardiology, Oregon Health and Science University, 707 SW Gaines Street, Mail code: CDRC-P, Portland, OR, 97239, USA
| | - Seshadri Balaji
- Division of Pediatric Cardiology, Oregon Health and Science University, 707 SW Gaines Street, Mail code: CDRC-P, Portland, OR, 97239, USA
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4
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Mahendran AK, Katz D, Opotowsky AR, Lubert AM. Exercise Pathophysiology and Testing in Individuals With a Fontan Circulation. CJC PEDIATRIC AND CONGENITAL HEART DISEASE 2023; 2:112-123. [PMID: 37969357 PMCID: PMC10642126 DOI: 10.1016/j.cjcpc.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/07/2023] [Indexed: 11/17/2023]
Abstract
The Fontan circulation, a surgical palliation for single-ventricle congenital heart disease, profoundly impacts the cardiopulmonary response to exercise. Reliant on passive pulmonary blood flow, the Fontan circulation has limited capacity to augment cardiac output as necessary to supply working muscles during exercise. Cardiopulmonary exercise testing (CPET) objectively assesses cardiorespiratory fitness and provides insight into the etiology of exercise intolerance. Furthermore, CPET variables, such as peak oxygen consumption and submaximal variables, have prognostic value and may be used as meaningful endpoints in research studies. CPET is also useful in clinical research applications to assess the effect of pharmacologic or other interventions. Medical therapies to improve exercise tolerance in individuals with a Fontan circulation, such as pulmonary vasodilators, may modestly improve peak oxygen consumption. Exercise training focused on aerobic fitness and lower extremity strength may have a more consistent and larger impact on these measures of aerobic fitness. CPET is a valuable diagnostic and prognostic tool for those with a Fontan circulation. Newer ancillary assessments, such as noninvasive peripheral venous pressure monitoring and cardiac output measurements, hold promise to provide a more nuanced insight into the underlying pathophysiology.
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Affiliation(s)
- Arjun K. Mahendran
- Department of Pediatrics, Heart Institute, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - David Katz
- Department of Pediatrics, Heart Institute, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Alexander R. Opotowsky
- Department of Pediatrics, Heart Institute, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Adam M. Lubert
- Department of Pediatrics, Heart Institute, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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5
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Mondésert B, Moore JP, Khairy P. Cardiac Implantable Electronic Devices in the Fontan Patient. Can J Cardiol 2022; 38:1048-1058. [PMID: 35588949 DOI: 10.1016/j.cjca.2022.04.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 04/18/2022] [Accepted: 04/19/2022] [Indexed: 12/22/2022] Open
Abstract
As a result of remarkable progress in operative techniques and cardiology care during childhood, Fontan patients continue to age and require team-based multidisciplinary expertise to manage complications encountered in adulthood. They face particular challenges in terms of altered hemodynamic stressors, cardiac and hepatic failure, and arrhythmias. Arrhythmias in Fontan patients are highly prevalent and associated with underlying anatomy, surgical technique, and postoperative sequelae. Diagnostic tools, treatments, and device strategies for arrhythmias in Fontan patients should be adapted to the specific anatomy, type of surgical repair, and clinical status. Great strides in our understanding of arrhythmia mechanisms, options and techniques to obtain access to relevant cardiac structures, and application of both old and new technologies have contributed to improving cardiac implantable electronic device (CIED) therapies for this unique population. In this state-of-the-art review, we discuss the various arrhythmias encountered in Fontan patients, their diagnosis, and options for treatment and prevention, with a focus on CIEDs. Throughout, access challenges particular to the Fontan circulation are considered. Recently developed technologies, such as the sub-cutaneous implantable cardioverter defibrillator carry the potential to be transformative but require awareness of Fontan-specific issues. Moreover, new leadless pacing technology represents a promising strategy that may soon become applicable to Fontan patients with sinus node dysfunction. CIEDs are essential tools in managing Fontan patients but the complex clinical scenarios that arise in this patient population are among the most challenging for the congenital electrophysiologist.
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Affiliation(s)
- Blandine Mondésert
- Adult Congenital Heart Disease Center, Montreal Heart Institute, Medicine Department, Université de Montréal, Montreal, Canada.
| | - Jeremy P Moore
- Division of Cardiology, Department of Medicine, Ahmanson/UCLA Adult Congenital Heart Disease Center, Los Angeles, CA; UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, CA; Division of Cardiology, Department of Pediatrics, UCLA Health System, Los Angeles, CA
| | - Paul Khairy
- Adult Congenital Heart Disease Center, Montreal Heart Institute, Medicine Department, Université de Montréal, Montreal, Canada
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Alnoor M, Burch G, Armsby L, Batra A, Balaji S. Hemodynamic Impact of Atrial Pacing in Patients with Fontan Physiology and Junctional Rhythm: A Cardiac Catheterization Study. Pediatr Cardiol 2022; 43:508-514. [PMID: 34661729 DOI: 10.1007/s00246-021-02747-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/29/2021] [Indexed: 11/24/2022]
Abstract
Sinus node dysfunction is a common problem and adversely impacts patients who have undergone the Fontan operation. In Fontan patients with an adequate junctional escape rhythm, the benefit of atrial pacing to restore atrioventricular synchrony remains unclear. Data were collected retrospectively on all Fontan patients with junctional rhythm who underwent atrial pacing during cardiac catheterization. Hemodynamics were obtained at baseline and after atrial pacing for 5-10 min. Seven patients, mean age 10 years (3-21) were studied. The type of Fontan was extracardiac in 6 and lateral tunnel in one. Patients were paced at 10 bpm faster than their junctional rate. With pacing, there was a significant decrease in left atrial pressure from (mean ± SEM) 8.8 ± 2.6 to 5.5 ± 2.9 mmHg (p = 0.02), a significant increase in cardiac index from 2.7 ± 0.8 to 3.5 ± 1 L/min/m2 (p = 0.01) and pulmonary blood flow from 2.1 ± 0.6 to 2.7 ± 0.7 L/min/m2 (p = 0.001), and no significant change in pulmonary artery pressure, from 13.4 ± 2.8 to 12.4 mmHg ± 3.6 (p = 0.06) or pulmonary vascular resistance from 2.1 ± 0.86 to 3.25 ± 1.9 WU × M2 (p = 0.1). In Fontan patients with junctional rhythm, atrial pacing decreased the left atrial pressure, increased cardiac output and did not significantly change the pulmonary artery pressure. Our study supports further investigation into the utility of prophylactic atrial pacemaker implantation in Fontan patients with significant durations of JR on ambulatory monitoring.
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Affiliation(s)
- Mohammad Alnoor
- Division of Cardiology, Department of Pediatrics, Oregon Health & Science University, 700 SW Campus Dr, Portland, OR, 97239, USA.
| | - Grant Burch
- Division of Cardiology, Department of Pediatrics, Oregon Health & Science University, 700 SW Campus Dr, Portland, OR, 97239, USA
| | - Laurie Armsby
- Division of Cardiology, Department of Pediatrics, Oregon Health & Science University, 700 SW Campus Dr, Portland, OR, 97239, USA
| | - Anjan Batra
- Division of Cardiology, Department of Pediatrics, University of California-Irvine, Irvine, CA, USA
| | - Seshadri Balaji
- Division of Cardiology, Department of Pediatrics, Oregon Health & Science University, 700 SW Campus Dr, Portland, OR, 97239, USA
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7
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Driesen BW, Voskuil M, Grotenhuis HB. Current Treatment Options for the Failing Fontan Circulation. Curr Cardiol Rev 2022; 18:e060122200067. [PMID: 34994331 PMCID: PMC9893132 DOI: 10.2174/1573403x18666220106114518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 10/22/2021] [Accepted: 11/16/2021] [Indexed: 11/22/2022] Open
Abstract
The Fontan operation was introduced in 1968. For congenital malformations, where biventricular repair is unsuitable, the Fontan procedure has provided a long-term palliation strategy with improved outcomes compared to the initially developed procedures. Despite these improvements, several complications merely due to a failing Fontan circulation, including myocardial dysfunction, arrhythmias, increased pulmonary vascular resistance, protein-losing enteropathy, hepatic dysfunction, plastic bronchitis, and thrombo-embolism, may occur, thereby limiting the life-expectancy in this patient cohort. This review provides an overview of the most common complications of Fontan circulation and the currently available treatment options.
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Affiliation(s)
- Bart W. Driesen
- Department of Pediatric Cardiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Utrecht, The Netherlands
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Cardiology, Laurentius Ziekenhuis, Roermond, The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Heynric B. Grotenhuis
- Department of Pediatric Cardiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Utrecht, The Netherlands
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8
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Joyce J, O'Leary ET, Mah DY, Harrild DM, Rhodes J. Cardiac resynchronization therapy improves the ventricular function of patients with Fontan physiology. Am Heart J 2020; 230:82-92. [PMID: 33017579 DOI: 10.1016/j.ahj.2020.09.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 09/27/2020] [Indexed: 11/16/2022]
Abstract
Past studies have not detected consistent improvement in ventricular function (VFxn) following initiation of cardiac resynchronization therapy (CRT) in Fontan patients. However, these studies used qualitative assessments of VFxn and/or quantitative assessments of VFxn that rely upon anatomic and/or geometric assumptions that may not be valid in patients with single ventricles. To address this, we used quantitative indices of global VFxn (dP/dtic and the Tei index) that are not encumbered by the limitations associated with the indices used in previous studies of CRT in Fontan patients. METHODS Patients with Fontan physiology who had received CRT therapy from 2004 to 2019 were included in the study. They were compared to a concurrent group of Fontan patients who had received standard dual-chamber pacemakers (DCPMs). RESULTS VFxn was assessed at 3 time points: prior to, shortly after, and late after initiation of pacemaker therapy. Prior to initiation of pacemaker therapy, VFxn of the CRT patients tended to be worse than that of the DCPM patients. For both groups, VFxn appeared to be stable or slightly improved shortly after initiation of pacemaker therapy. In the CRT group, VFxn improved significantly between early and late follow-up. In contrast, VFxn in DCPM patients tended to decline during this period. Changes in VFxn correlated with concurrent changes in New York Heart Association classification. CONCLUSIONS Quantitative assessments of VFxn using indices not confounded by complex cardiac anatomy, segmental wall motions abnormalities, or inappropriate geometric assumptions revealed that CRT in Fontan patients is associated with preservation or improvement VFxn compared to standard DCPM. Changes in VFxn correlate with concurrent changes in New York Heart Association classification.
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Affiliation(s)
- Jeremiah Joyce
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA
| | - Edward T O'Leary
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA
| | - Douglas Y Mah
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA
| | - David M Harrild
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA
| | - Jonathan Rhodes
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Ave, Boston, MA.
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9
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Kochav JD, Rosenbaum M, Kochav SM, Slater E, Wassercug-Zemer N, Lewis MJ. Effect of Ventricular Pacing on Morbidity in Adults After Fontan Repair. Am J Cardiol 2020; 125:1263-1269. [PMID: 32081367 DOI: 10.1016/j.amjcard.2020.01.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 01/12/2020] [Accepted: 01/15/2020] [Indexed: 12/12/2022]
Abstract
Implantation of a permanent pacemaker is a negative prognostic marker in patients with Fontan palliation; however, data delineating outcomes in adult patients with pacemaker requirements are lacking. We hypothesize that high ventricular pacing burden is associated with adverse outcomes in adult Fontan patients. We performed a retrospective review comprising adult patients with history of Fontan repair. A high burden of ventricular pacing was defined as ≥40% pacing. Major adverse clinical events (MACE) were defined as all-cause mortality or need for advanced cardiac therapies (ventricular assist device or heart transplant). A total of 145 adult patients with Fontan were studied for a median of 3.1 years. Twenty (14%) patients had implanted pacemakers with ≥40% ventricular pacing. Twelve events occurred in those with ≥40% ventricular pacing (incidence 60.0%) versus 11 in those without (incidence 8.8%). In multivariable analysis, ≥40% ventricular-pacing (odds ratio 12.51, confidence interval [CI] 3.56 to 43.83, p <0.001) was associated with MACE independent of initial Fontan type, New York Heart Association functional class at baseline, or history of atrial tachyarrythmia. In survival analysis, patients with ≥40% ventricular pacing had nearly 8 times the risk of MACE compared with those with a lower ventricular pacing burden (hazard ratio 7.79, 95% CI 2.56 to 23.66, p <0.001), whereas patients with atrial-only or <40% ventricular pacing burden had a trend toward higher hazard of MACE compared with those without permanent pacemaker (hazard ratio 3.38, 95% CI 0.92 to 12.47, p = 0.07) that did not meet statistical significance. These findings suggest that high ventricular pacing burden contributes to poor outcomes in the adult Fontan patients and bear consideration when determining optimal treatment of tachyarrhythmias in this population.
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Affiliation(s)
- Jonathan D Kochav
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Marlon Rosenbaum
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Stephanie M Kochav
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Emily Slater
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Noa Wassercug-Zemer
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York
| | - Matthew J Lewis
- Department of Cardiology, Columbia University Irving Medical Center, New York, New York.
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10
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Rychik J, Atz AM, Celermajer DS, Deal BJ, Gatzoulis MA, Gewillig MH, Hsia TY, Hsu DT, Kovacs AH, McCrindle BW, Newburger JW, Pike NA, Rodefeld M, Rosenthal DN, Schumacher KR, Marino BS, Stout K, Veldtman G, Younoszai AK, d'Udekem Y. Evaluation and Management of the Child and Adult With Fontan Circulation: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e234-e284. [PMID: 31256636 DOI: 10.1161/cir.0000000000000696] [Citation(s) in RCA: 407] [Impact Index Per Article: 81.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
It has been 50 years since Francis Fontan pioneered the operation that today bears his name. Initially designed for patients with tricuspid atresia, this procedure is now offered for a vast array of congenital cardiac lesions when a circulation with 2 ventricles cannot be achieved. As a result of technical advances and improvements in patient selection and perioperative management, survival has steadily increased, and it is estimated that patients operated on today may hope for a 30-year survival of >80%. Up to 70 000 patients may be alive worldwide today with Fontan circulation, and this population is expected to double in the next 20 years. In the absence of a subpulmonary ventricle, Fontan circulation is characterized by chronically elevated systemic venous pressures and decreased cardiac output. The addition of this acquired abnormal circulation to innate abnormalities associated with single-ventricle congenital heart disease exposes these patients to a variety of complications. Circulatory failure, ventricular dysfunction, atrioventricular valve regurgitation, arrhythmia, protein-losing enteropathy, and plastic bronchitis are potential complications of the Fontan circulation. Abnormalities in body composition, bone structure, and growth have been detected. Liver fibrosis and renal dysfunction are common and may progress over time. Cognitive, neuropsychological, and behavioral deficits are highly prevalent. As a testimony to the success of the current strategy of care, the proportion of adults with Fontan circulation is increasing. Healthcare providers are ill-prepared to tackle these challenges, as well as specific needs such as contraception and pregnancy in female patients. The role of therapies such as cardiovascular drugs to prevent and treat complications, heart transplantation, and mechanical circulatory support remains undetermined. There is a clear need for consensus on how best to follow up patients with Fontan circulation and to treat their complications. This American Heart Association statement summarizes the current state of knowledge on the Fontan circulation and its consequences. A proposed surveillance testing toolkit provides recommendations for a range of acceptable approaches to follow-up care for the patient with Fontan circulation. Gaps in knowledge and areas for future focus of investigation are highlighted, with the objective of laying the groundwork for creating a normal quality and duration of life for these unique individuals.
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11
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O'Leary ET, Gauvreau K, Alexander ME, Banka P, Bezzerides VJ, Fynn-Thompson F, Triedman JK, Walsh EP, Mah DY. Dual-Site Ventricular Pacing in Patients With Fontan Physiology and Heart Block: Does it Mitigate the Detrimental Effects of Single-Site Ventricular Pacing? JACC Clin Electrophysiol 2018; 4:1289-1297. [PMID: 30336874 DOI: 10.1016/j.jacep.2018.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 06/25/2018] [Accepted: 07/06/2018] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This study sought to determine the long-term effect of dual-site ventricular pacing (i.e., cardiac resynchronization therapy [CRT]) versus single-site pacing in patients with Fontan physiology and high-grade atrioventricular block (AVB). BACKGROUND Chronic single-site ventricular pacing in Fontan patients is associated with significant morbidity and mortality. METHODS The study conducted a retrospective review of all Fontan patients with high-grade AVB who received pacemakers at a single institution between 1990 and 2016 with follow-up of 12 months or greater. The primary study outcome was a composite of death or heart transplantation. RESULTS Nineteen patients received CRT devices and 43 patients received single-site ventricular pacemakers (SVPMs), with a median follow-up of 4.9 years (range 1.1 to 11.3 years) and 10.4 years (range 1.1 to 26.8 years), respectively. One (5.3%) CRT patient and 11 (25.6%) SVPM patients reached the composite endpoint of death or transplant (odds ratio: 0.16; 95% confidence interval: 0.02 to 1.36; p = 0.09). Kaplan-Meier analysis showed similar rates of freedom from death or transplant between the 2 study groups over a 5-year follow-up period (p = 0.08). The proportion of SVPM patients with abnormal ventricular systolic function before device implantation (9.5%) and at follow-up (33.3%) significantly increased (p=0.009). The CRT cohort had less change in their ventricular function (42.1% before device implant, 36.8% at follow-up; p = 1.00); however, a Kaplan-Meier analysis over a 5-year follow-up period found no difference in the presence of abnormal ventricular systolic function between groups (p = 0.27). CONCLUSIONS There was no significant difference in long-term outcomes between Fontan patients who were single- or dual-site paced for high-grade AVB.
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Affiliation(s)
- Edward T O'Leary
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Mark E Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Puja Banka
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | | | | | - John K Triedman
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Edward P Walsh
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Douglas Y Mah
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts.
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Cecchin F, Halpern DG. Cardiac Arrhythmias in Adults with Congenital Heart Disease: Pacemakers, Implantable Cardiac Defibrillators, and Cardiac Resynchronization Therapy Devices. Card Electrophysiol Clin 2017; 9:319-328. [PMID: 28457245 DOI: 10.1016/j.ccep.2017.02.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Implanting cardiac rhythm medical devices in adults with congenital heart disease requires training in congenital heart disease. The techniques and indications for device implantation are specific to the anatomic diagnosis and state of disease progression. It often requires a team of physicians and is best performed at a specialized adult congenital heart center.
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Affiliation(s)
- Frank Cecchin
- NYU Langone Medical Center, 550 First Avenue, New York, NY 10016, USA.
| | - Daniel G Halpern
- NYU Langone Medical Center, 550 First Avenue, New York, NY 10016, USA
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Trans-Fontan baffle placement of an endocardial systemic ventricular pacing lead. HeartRhythm Case Rep 2017; 3:129-132. [PMID: 28491786 PMCID: PMC5420057 DOI: 10.1016/j.hrcr.2016.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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O’Leary E, Alexander ME, Fynn-Thompson F, Mah D. Transvenous approach to pacemaker lead implantation for sinus node dysfunction after extracardiac lateral tunnel Fontan conduit placement. HeartRhythm Case Rep 2016; 2:495-498. [PMID: 28491745 PMCID: PMC5419993 DOI: 10.1016/j.hrcr.2016.07.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Affiliation(s)
- Edward O’Leary
- Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Address reprint requests and correspondence: Dr Edward O’Leary, Department of Cardiology, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115.Department of Cardiology, Boston Children’s Hospital, 300 Longwood AvenueBostonMA02115
| | - Mark E. Alexander
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | | | - Douglas Mah
- Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
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Mah DY, Cheng H, Alexander ME, Sleeper L, Newburger JW, del Nido PJ, Thiagarajan RR, Rajagopal SK. Heart block following stage 1 palliation of hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2016; 152:189-94. [DOI: 10.1016/j.jtcvs.2016.03.074] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 03/25/2016] [Accepted: 03/31/2016] [Indexed: 11/28/2022]
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Omerbasic E, Karabdic IH, Tahirovic E. Successful Implantation of Bipolar Epicardial Leads and Dual Chamber Pacemaker in Infant After Postoperative Atrioventricular Heart Block. Acta Inform Med 2015; 23:177-8. [PMID: 26236087 PMCID: PMC4499303 DOI: 10.5455/aim.2015.23.177-178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 05/11/2015] [Indexed: 11/29/2022] Open
Abstract
Total atrioventricular (AV) block is inconvenient and serious complication of open heart surgery. Permanent total AV block requires the implantation of permanent pacemaker in order to allow normal hemodynamics and patient’s survival. In infancy additional challenge is the surgical approach, the selection of electrodes and PM, as well as place of implantation. We are publishing case report of successful double-chamber DDD pacemaker implantation at an infant born with Fallot tetralogy and with low birth weight due to complete AV block after primary surgical correction of these congenital defects.
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Affiliation(s)
- Edin Omerbasic
- Institute for heart disease, Cardiothoracic Clinic, Clinical Center University of Sarajevo, Bosnia and Herzegovina
| | | | - Elnur Tahirovic
- Institute for heart disease, Cardiothoracic Clinic, Clinical Center University of Sarajevo, Bosnia and Herzegovina
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Silvetti MS, Drago F, Di Carlo D, Placidi S, Brancaccio G, Carotti A. Cardiac pacing in paediatric patients with congenital heart defects: transvenous or epicardial? Europace 2013; 15:1280-6. [PMID: 23439868 DOI: 10.1093/europace/eut029] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS Cardiac pacing is a difficult technique in children, particularly in patients with congenital heart defects (CHDs). Few studies to date have addressed this topic. METHODS AND RESULTS We performed a retrospective analysis of the results of a single centre. Between 1982 and 2008, 287 patients with CHD, median age of 5 years (25-75%, 1-11) underwent cardiac pacing for sinus node dysfunction (SND) and atrioventricular block (AVB); 97% of patients underwent at least one heart surgery. Endocardial systems (Endo) were implanted in 117 patients, epicardial systems (Epi) in 170, with 595 leads (228 Endo, 367 Epi). Endocardial systems showed a significantly older age group with more frequent SND; Epi a younger age group, with more frequent AVB, greater number of surgical interventions. Perioperative complications were mortality 0.6% (Epi), pericardial effusion 0.6% (Epi), and haemothorax 3.4% (Endo). The median follow-up is 5 (2-10) years: the pacing system failed in 29% of patients, 13% Endo, and 40% Epi (P < 0.0001). Multivariate analysis showed a significantly higher risk of failure for Epi, a lower implant age, greater the number of leads implanted. The risk of malfunction of the leads increases significantly for Epi and the younger age when implanted. The steroid-eluting leads have a lower risk of malfunction (P = 0.05), steroid-eluting Endo leads provide significantly better outcomes than Epi. CONCLUSION Cardiac pacing in paediatric patients with CHD shows satisfactory results in the long term. Endocardial systems show significantly better results than Epi systems. A younger age when implanted is a risk factor for complications at follow-up.
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Affiliation(s)
- Massimo Stefano Silvetti
- Unità Operativa di Aritmologia/Syncope Unit, Dipartimento Medico-Chirurgico di Cardiologia Pediatrica Bambino Gesu` Children’s Hospital, IRCCS, Piazza S. Onofrio 4, 00165 Rome, Italy.
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Williams RV, Travison T, Kaltman JR, Cecchin F, Colan SD, Idriss SF, Lu M, Margossian R, Reed JH, Silver ES, Stephenson EA, Vetter VL. Comparison of Fontan survivors with and without pacemakers: a report from the Pediatric Heart Network Fontan Cross-Sectional Study. CONGENIT HEART DIS 2012; 8:32-9. [PMID: 22762157 DOI: 10.1111/j.1747-0803.2012.00692.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/22/2012] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Although many Fontan patients undergo pacemaker placement, there are few studies characterizing this population. Our purpose was to compare clinical characteristics, functional status and measures of ventricular performance in Fontan patients with and without a pacemaker. PATIENTS AND DESIGN The National Heart, Lung, and Blood Institute funded Pediatric Heart Network Fontan Cross-Sectional Study characterized 546 Fontan survivors. Clinical characteristics, medical history and study outcomes (Child Health Questionnaire [CHQ]), echocardiographic evaluation of ventricular function, and exercise testing) were compared between subjects with and without pacemakers. RESULTS Of 71 subjects with pacemakers (13%), 43/71 (61%) were in a paced rhythm at the time of study enrollment (age 11.9 ± 3.4 years). Pacemaker subjects were older at study enrollment, more likely to have single left ventricles, and taking more medications. There were no differences in age at Fontan or Fontan type between the pacemaker and no pacemaker groups. There were no differences in exercise performance between groups. CHQ physical summary scores were lower in the pacemaker subjects (39.7 ± 14.3 vs. 46.1 ± 11.2, P =.001). Ventricular ejection fraction z-score was also lower (-1.4 ± 1.9 vs. -0.8 ± 2.0, P =.05) in pacemaker subjects. CONCLUSIONS In our cohort of Fontan survivors, those with a pacemaker have poorer functional status and evidence of decreased ventricular systolic function compared to Fontan survivors without a pacemaker.
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Stephenson EA, Lu M, Berul CI, Etheridge SP, Idriss SF, Margossian R, Reed JH, Prakash A, Sleeper LA, Vetter VL, Blaufox AD. Arrhythmias in a contemporary fontan cohort: prevalence and clinical associations in a multicenter cross-sectional study. J Am Coll Cardiol 2010; 56:890-6. [PMID: 20813285 DOI: 10.1016/j.jacc.2010.03.079] [Citation(s) in RCA: 130] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Revised: 02/17/2010] [Accepted: 03/18/2010] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Our aim was to examine the prevalence of arrhythmias and identify independent associations of time to arrhythmia development. BACKGROUND Since introduction of the Fontan operation in 1971, long-term results have steadily improved with newer modifications. However, atrial arrhythmias are frequent and contribute to ongoing morbidity and mortality. Data are lacking regarding the prevalence of arrhythmias and risk factors for their development in the current era. METHODS The Pediatric Heart Network Fontan Cross-Sectional study evaluated data from 7 centers, with 520 patients age 6 to 18 years (mean 8.6 +/- 3.4 years after the Fontan operation), including echocardiograms, electrocardiograms, exercise testing, parent-reported Child Health Questionnaire (CHQ) results, and medical history. RESULTS Supraventricular tachycardias were present in 9.4% of patients. Intra-atrial re-entrant tachycardia (IART) was present in 7.3% (32 of 520). The hazard of IART decreased until 4 to 6 years post-Fontan, and then increased with age thereafter. Cardiac anatomy and resting heart rate (including marked bradycardia) were not associated with IART. We identified 3 independent associations of time to occurrence of IART: lower CHQ physical summary score (p < 0.001); predominant rhythm (p = 0.002; highest risk with paced rhythm), and type of Fontan operation (p = 0.037; highest risk with atriopulmonary connection). Time to IART did not differ between patients with lateral tunnel and extracardiac conduit types of Fontan repair. Ventricular tachycardia was noted in 3.5% of patients. CONCLUSIONS Overall prevalence of IART was lower in this cohort (7.3%) than previously reported. Lower functional status, an atriopulmonary connection, and paced rhythm were determined to be independently associated with development of IART after Fontan. (Relationship Between Functional Health Status and Ventricular Performance After Fontan-Pediatric Heart Network; NCT00132782).
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Takahashi K, Cecchin F, Fortescue E, Berul CI, Alexander ME, Walsh EP, Fynn-Thompson F, Triedman JK. Permanent atrial pacing lead implant route after Fontan operation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2009; 32:779-85. [PMID: 19545341 DOI: 10.1111/j.1540-8159.2009.02365.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Atrial pacing is indicated for sinus node dysfunction (SND) after Fontan surgery; preferred lead implantation technique is debated. We compare outcomes of transvenous (TV) and epicardial (Epi) atrial lead implants in this population. METHODS Retrospective review of Fontan patients undergoing atrial lead implant between 1992 and 2007. Demographics, lead performance data, and outcomes were analyzed. RESULTS 78 patients had 90 leads implanted: 25 via TV route and 65 via Epi route. Median follow-up was 1.6 years (TV) and 3.6 years (Epi). TV leads were implanted in older patients (23.1 vs 9.3 years, P < 0.001) and at longer intervals after Fontan (15.2 vs 4.9 years, P < 0.001). Pacing indication for most TV leads was SND, while Epi leads were also indicated for atrioventricular block. Acute complication rates were similar (8% TV vs 19% Epi, P = 0.23), but median hospital stay was shorter for TV (2 vs 5 days, P = 0.03). Thrombus was observed in five patients (two in TV; three in Epi), but no thromboembolic events were observed. Mean lead survival was similar (TV 9.9 vs Epi 7.8 years, P = NS). Energy threshold was lower at implant for TV leads (0.9 vs 2.2 microJ, P = 0.049), but similar at follow-up (1.2 vs 2.6 microJ, P = 0.35). Atrial sensing was unchanged over time for TV (2.2 to 2.1 mV, P = NS), but decreased for Epi (3.3 to 2.5 mV, P = 0.02). CONCLUSIONS Compared to epicardial leads, transvenous atrial pacing leads may be placed in Fontan patients with lower procedural morbidity and equivalent expectation of lead performance and longevity.
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Affiliation(s)
- Kazuhiro Takahashi
- Department of Cardiology, Children's Hospital Boston, Boston, MA 02115, USA
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Estner HL, Kolb C, Schmitt C, Deisenhofer I, Pflaumer A, Eicken A, Zrenner B, Hessling G. Long-term transvenous AV-sequential pacing in a failing atriopulmonary Fontan patient. Int J Cardiol 2008; 127:e93-5. [PMID: 17764764 DOI: 10.1016/j.ijcard.2007.04.085] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2007] [Accepted: 04/12/2007] [Indexed: 10/22/2022]
Abstract
UNLABELLED We report on a 32-year-old man with tricuspid atresia, pulmonary stenosis and hypoplastic right ventricle. He had received a Fontan-Kreutzer procedure (anastomosis between the right atrial appendage and the pulmonary artery) at the age of 14 years. At the age of 2 years, an abdominal VVI-pacemaker with an epicardial ventricular lead had been implanted because of symptomatic third degree AV-block. The patient was now hospitalized with symptoms of severe congestive heart failure. A least invasive approach restoration of AV-synchrony by a dual chamber pacer was performed. Therefore a complete transvenous approach to avoid thoracotomy was attempted. A specially designed CS lead was advanced via the CS to a left lateral ventricular vein for ventricular stimulation. After institution of dual chamber pacing the patient recovered of his heart failure. During a follow-up time of 20 months the patient was clinically stable in the AV-sequential pacing. CONCLUSION Dual chamber pacing using a transvenously placed coronary sinus lead for ventricular stimulation may improve congestive heart failure in patients after the classic Fontan operation. The minimally invasive transvenous approach might be the best solution for patients who need a pacemaker and are not candidates for surgery or heart transplantation.
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Functional status, heart rate, and rhythm abnormalities in 521 Fontan patients 6 to 18 years of age. J Thorac Cardiovasc Surg 2008; 136:100-7, 107.e1. [PMID: 18603061 DOI: 10.1016/j.jtcvs.2007.12.024] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2007] [Revised: 11/29/2007] [Accepted: 12/18/2007] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Our objective was to determine the relationship between functional outcome and abnormalities of heart rate and rhythm after the Fontan operation. METHODS The National Heart, Lung, and Blood Institute Pediatric Heart Network conducted a cross-sectional analysis of patients who had undergone a Fontan procedure at the 7 network centers. Analysis was based on 521 patients with an electrocardiogram (n = 509) and/or bicycle exercise test (n = 404). The Child Health Questionnaire parent report and the oxygen consumption at the anaerobic threshold were used as markers of functional outcome. RESULTS Various Fontan procedures had been performed: intracardiac lateral tunnel (59%), atriopulmonary connection (14%), extracardiac later tunnel (13%), and extracardiac conduit (11%). Prior volume unloading surgery was performed in 389 patients: bidirectional Glenn (70%) and hemi-Fontan (26%). A history of atrial tachycardia was noted in 9.6% of patients and 13.1% of patients had a pacemaker. Lower resting heart rate and higher peak heart rate were each weakly associated with better functional status, as defined by higher anaerobic threshold (R = -0.18, P = .004, and R = 0.16, P = .007, respectively) and higher Child Health scores for physical functioning (R = -0.18, P < .001, and R = 0.17, P = .002, respectively). Higher anaerobic threshold was also independently associated with younger age and an abnormal P-axis. Resting bradycardia was not associated with anaerobic threshold or Child Health scores. CONCLUSIONS In pediatric patients (6-18 years) after the Fontan procedure, a lower resting heart rate and a higher peak heart rate are each independently associated with better physical function as measured by anaerobic threshold and Child Health scores. However, these correlations are weak, suggesting that other, nonrhythm and nonrate, factors may have a greater impact on the functional outcome of pediatric patients after the Fontan operation.
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Barber BJ, Batra AS, Burch GH, Shen I, Ungerleider RM, Brown JW, Turrentine MW, Mori M, Hsieh YC, Balaji S. Acute Hemodynamic Effects of Pacing in Patients With Fontan Physiology. J Am Coll Cardiol 2005; 46:1937-42. [PMID: 16286183 DOI: 10.1016/j.jacc.2005.07.045] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2005] [Revised: 05/24/2005] [Accepted: 07/05/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The purpose of this research was to assess the hemodynamic response to atrial, ventricular, and dual-chamber pacing in patients with Fontan physiology. BACKGROUND Bradycardia, due to sinus node dysfunction or atrioventricular (AV) block, with need for pacing, is common after the Fontan operation. The optimal pacing mode for Fontan patients is unknown, but is critical, as hemodynamic aberrancies may cause severe clinical deterioration. We hypothesized that AV synchrony is vital for maximizing Fontan hemodynamics. METHODS A cross-over trial was conducted with 21 patients (age 2 to 18 years, median 4 years; male patients = 13) in the intensive care unit after a Fontan operation. Hemodynamic parameters, including mean left atrial pressure (LAP, in mm Hg), mean pulmonary artery pressure (PAP, in mm Hg), mean arterial blood pressure (MAP, in mm Hg), and indexed cardiac output via Fick (Qs, in l/min/m2) were measured with atrial, ventricular, and dual-chamber pacing. Measurements were made after pacing for 10 min in each mode, and a 10-min rest was given between each pacing maneuver. RESULTS Asynchronous ventricular (VOO) pacing resulted in significantly worse hemodynamics when compared to dual-chamber (DOO) and atrial (AOO) pacing with a higher LAP (9.4 VOO; 6.8 DOO; 5.4 AOO) and PAP (15.2 VOO; 13.5 DOO; 12.7 AOO) and lower Qs (3.0 VOO; 3.5 DOO; 3.9 AOO) and MAP (60.1 VOO; 66.5 DOO; 67.2 AOO). CONCLUSIONS Asynchronous ventricular pacing, after the Fontan procedure, has acute, adverse hemodynamic consequences (elevated LAP and PAP and decreased Qs and MAP).
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Affiliation(s)
- Brent J Barber
- Department of Pediatric Cardiology, Oregon Health & Science University, Portland, Oregon, USA.
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Dodge-Khatami A, Rahn M, Prêtre R, Bauersfeld U. Dual Chamber Epicardial Pacing for the Failing Atriopulmonary Fontan Patient. Ann Thorac Surg 2005; 80:1440-4. [PMID: 16181884 DOI: 10.1016/j.athoracsur.2005.03.128] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2005] [Revised: 03/29/2005] [Accepted: 03/30/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND The atriopulmonary Fontan circulation leads to arrhythmias, heart failure, or protein-losing enteropathy, eventually requiring conversion. In hesitant patients, we evaluated the effect of dual chamber pacing as a time-buying measure. METHODS Between 1997 and 2004, 9 patients (aged, 6 to 18 years) with an atriopulmonary Fontan connection and sinus node dysfunction received dual chamber epicardial pacemaker systems. Indications included refractory arrhythmias (n = 5), protein-losing enteropathy (n = 2), heart failure with effusions (n = 1), and exercise intolerance (n = 2). Data were compared between hospital discharge after pacemaker implantation and last follow-up. RESULTS There was no mortality or morbidity. At a follow-up of 3.3 +/- 1.0 years, lead survival was 100%. Both atrial (impedance = 683 +/- 40 Ohm; threshold = 0.8 +/- 0.1 V at 0.5 ms; sensing P waves = 3.3 +/- 0.8 mV) and ventricular (impedance = 630 +/- 68 Ohm; threshold = 1.3 +/- 0.3 V at 0.5 ms; sensing R waves = 8.7 +/- 2.5 mV) leads retained satisfactory pacing characteristics at last control, better than those at discharge. Arrhythmias subsided in all instances and no longer required medication in 3 patients. Protein-losing enteropathy improved temporarily in 1 patient and disappeared in another. Exercise intolerance diminished, and heart failure was controlled. CONCLUSIONS Although most atriopulmonary Fontan circulations will need conversion with arrhythmia surgery, patients may delay out of fear. Dual chamber pacing improves single ventricle hemodynamics and can help decompensated Fontan patients. In a multiple-redo setting, a left lateral thoracotomy provides safe access and allows for quantitatively reliable and durable epicardial pacing.
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Affiliation(s)
- Ali Dodge-Khatami
- Division of Cardiovascular Surgery, University Children's Hospital Zürich, Zürich, Switzerland.
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Hasselman T, Schneider D, Madan N, Jacobs M. Reversal of fenestration flow during ventricular systole in Fontan patients in junctional or ventricular paced rhythm. Pediatr Cardiol 2005; 26:638-41. [PMID: 16132285 DOI: 10.1007/s00246-005-0879-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Sinus node dysfunction is relatively common in patients with Fontan palliation for single ventricle congenital heart disease, and such patients often are in junctional rhythm or may have pacemaker systems for bradycardia. Because the physiologic determinants of left atrial pressure play a major role in determining pulmonary blood flow and therefore cardiac output in Fontan patients, the loss of atrioventricular (AV) synchrony in junctional rhythm or demand ventricular pacing in these patients might be expected to influence cardiac output. We report two cases of Fontan patients with the absence of AV synchrony that resulted in reversal of flow through the Fontan fenestration during ventricular systole. In both cases, restoration of AV synchrony by atrial pacing resulted in the elimination of retrograde fenestration flow, increased cardiac output, and improved clinical status.
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Affiliation(s)
- T Hasselman
- University of Illinois at Chicago School of Medicine at Peoria, Children's Hospital of Illinois, 420 NE Glen Oak Avenue, Suite 304, Peoria, IL 61603, USA
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Abstract
We describe 17 patients (8 girls, and 9 boys), aged 9.6 +/- 5.7 years, with paroxysmal atrioventricular block (PAVB), a condition rarely described in children. Holter monitoring documented the PAVB in 15 patients, and tilt test was performed in 4 patients (positive in 1). The electrocardiograph (ECG) was normal in 7 patients. Two patients had acquired and 11 patients had congenital heart disease (CHD). Syncope or presyncope were present in 7 patients. A normal ECG was significantly more frequent in symptomatic patients. Pauses were significantly longer in girls and in children <5 years. PAVB was recorded only during nocturnal hours in 6 patients and throughout the day in the others. The sinus rate decreased during PAVB in 6 patients and increased in 4 (generally younger girls with symptoms). Permanent pacemakers were implanted in 13 patients, including 7 asymptomatic patients with CHD and severe bradycardia. During follow-up (3.7 +/- 2.5 years), 1 patient developed complete AVB. Although PAVB was still present in 91% of paced patients, symptoms did not recur because pacing prevented the pauses. In conclusion, PAVB is a rare arrhythmia. Autonomic nervous system dysfunction seems to play an etiological role and permanent pacing was an effective treatment.
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Affiliation(s)
- M S Silvetti
- Cardiac Arrhythmias Service, Cardiology and Heart Surgery Department, Bambino Gesù Pediatric Hospital, Piazza S. Onofrio 4, 00165, Rome, Italy.
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Walker F, Siu SC, Woods S, Cameron DA, Webb GD, Harris L. Long-Term outcomes of cardiac pacing in adults with congenital heart disease. J Am Coll Cardiol 2004; 43:1894-901. [PMID: 15145118 DOI: 10.1016/j.jacc.2003.12.044] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2003] [Revised: 12/17/2003] [Accepted: 12/23/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The purpose of this retrospective study was to define long-term outcomes after pacemaker therapy in adults with congenital heart disease (CHD). BACKGROUND Adults with CHD represent a unique and expanding population. Many will require pacemaker or implantable defibrillator therapy, with a lifelong need for re-intervention and follow-up. They pose technical and management challenges not encountered in other groups receiving pacing, and the complication and re-intervention rates specific to this population are not well-defined. METHODS We reviewed outcomes of 168 adults with CHD, 89 females, mean age 40 years, in whom a pacemaker or anti-tachycardia device was implanted. RESULTS Mean age at implant was 28 years with mean pacing duration 11 years at follow-up (range, 0.5 to 38.0). Seventy-two (42%) received initial dual-chamber devices and remained in this mode, while 23 (14%) went from ventricular to dual-chamber pacing in follow-up. Initial mode of pacing did not have a significant effect on subsequent atrial arrhythmia. Patients receiving an initial epicardial system were younger than those paced endocardially (17 +/- 12 years vs. 35 +/- 16 years, p < 0.001) and more likely to undergo re-intervention (p = 0.019). Difficulty with vascular access was encountered in 25 patients (15%), while 45 (27%) experienced lead-related complications. No significant predictors of lead complications were identified. CONCLUSIONS Lead complications were not significantly different for epicardial versus endocardial, nor physiologic versus ventricular pacing, but a trend toward improved lead survival in patients receiving endocardial leads at first implant was observed. Adults with CHD remain at risk for atrial arrhythmias regardless of pacing mode.
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Affiliation(s)
- Fiona Walker
- Toronto Congenital Cardiac Centre for Adults, Toronto General Hospital, Toronto, Ontario, Canada
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Abstract
There are special challenges associated with the use of transvenous pacemakers in children. For example, a child's chest cavity or vascular dimensions could be too small to host the generator and leads available or required. If leads are implanted, they may stretch as the child grows. This increases the risk that the leads will later dislodge or fracture. Moreover, children requiring pacemakers often have coexisting congenital heart defects and the structural abnormalities of those could hinder easy placement of the pacing system. This article will first review the indications for permanent pacing in children and will then describe the unique challenges associated with such use.
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Affiliation(s)
- Charles I Berul
- Department of Cardiology, Children's Hospital Boston, MA 02115, USA.
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Dretzke J, Toff WD, Lip GYH, Raftery J, Fry-Smith A, Taylor R. Dual chamber versus single chamber ventricular pacemakers for sick sinus syndrome and atrioventricular block. Cochrane Database Syst Rev 2004; 2004:CD003710. [PMID: 15106214 PMCID: PMC8095057 DOI: 10.1002/14651858.cd003710.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Dual chamber pacing or single chamber atrial pacing ('physiologic' pacing) is believed to have an advantage over single chamber ventricular pacing in that it resembles cardiac physiology more closely by maintaining atrioventricular (AV) synchrony and dominance of the sinus node, which in turn may reduce cardiovascular morbidity and mortality thus contributing to patient survival and quality of life. However, a significant proportion of pacemakers currently implanted are single chamber ventricular pacemakers. OBJECTIVES The objective of this review was to assess the short- and long-term clinical effectiveness of dual chamber pacemakers compared to single chamber ventricular pacemakers in adults with AV block, sick sinus syndrome or both. An additional objective was to assess separately any potential differences in effectiveness between dual chamber pacing and single chamber atrial pacing. The clinical effectiveness of single chamber atrial pacing versus single chamber ventricular pacing was not examined. SEARCH STRATEGY The Cochrane Controlled Trials Register (The Cochrane Library Issue 3, 2002), MEDLINE (1966 to 2002), EMBASE (1980 to 2002) and the Science Citation Index (1980 to 2002) were searched on 19th August 2002. Citation lists and web sites were checked and researchers in the field contacted. SELECTION CRITERIA Parallel group or crossover randomised controlled trials of at least 48 hours duration comparing dual chamber pacing and single chamber ventricular pacing, and investigating cardiovascular morbidity, mortality, patient related quality of life, exercise capacity and complication rates. DATA COLLECTION AND ANALYSIS Data was extracted onto pre-piloted data extraction forms. Quality assessment was undertaken using a checklist, with a sub-sample of quality data independently extracted by a second reviewer. Where appropriate data was available, meta-analysis was performed. Where meta-analysis was not possible, the number of studies showing a positive, neutral or negative direction of effect and statistical significance were simply counted. MAIN RESULTS Five parallel and 26 crossover randomised controlled trials were identified. The quality of reporting was found to be poor. Pooled data from parallel studies shows a statistically non-significant preference for physiologic pacing (primarily dual chamber pacing) for the prevention of stroke, heart failure and mortality, and a statistically significant beneficial effect regarding the prevention of atrial fibrillation (odds ratio (OR) 0.79, 95% CI 0.68 to 0.93). Both parallel and crossover studies favour dual chamber pacing with regard to pacemaker syndrome (parallel: Peto OR 0.11, 95% CI 0.08 to 0.14; crossover: standardised mean difference (SMD) -0.74, 95% CI - 0.95 to -0.52). Pooled data from crossover studies shows a statistically significant trend towards dual chamber pacing being more favourable in terms of exercise capacity (SMD -0.24, 95% CI -0.03 to -0.45). No individual studies reported a significantly more favourable outcome with single chamber ventricular pacing. REVIEWERS' CONCLUSIONS This review shows a trend towards greater effectiveness with dual chamber pacing compared to single chamber ventricular pacing, which supports the current British Pacing and Electrophysiology Group's Guidelines regarding atrioventricular block. Additional randomised controlled trial evidence from ongoing trials in this area will further inform the debate.
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Affiliation(s)
- J Dretzke
- Department of Public Health & Epidemiology, University of Birmingham, Edgbaston, Birmingham, UK, B15 2TT
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Abstract
Bradyarrhythmias developing after Fontan-type operations impair the function of the univentricular heart causing fatigue, headaches, ascites, and protein-losing enteropathy (PLE). Transvenous inaccessibility, requiring epicardial implantation, accounts for the reluctance to implant a pacemaker (PM). Between 1997 and 2000, 24 patients (mean age 9.5 years, range 6 months to 19 years) with Fontan-type operations received DDD pacing systems with atrial steroid-eluting stitch-on electrodes (mean capture threshold 1.9 V/0.5 ms, range 0.4-3.5 V) and ventricular screw-in electrodes (mean capture threshold 1.7 V/0.5 ms, range 0.1-3 V). The systems were implanted at the time of conversion from atrio- to cavopulmonary connections in 5 patients, at the time of a total cavopulmonary Fontan operation in 6, and 1-50 months thereafter (mean = 18) in 13 patients. A right ventricular anatomy was present in 13 (54%) of 24 of PM recipients, versus 35% of the overall population. After a mean follow-up of 3.5 years, the PM were functioning in DDD mode in 23 of the 24 patients. Length of hospital stay in the ten patients who underwent repeat sternotomy was 5 days, without procedure related complications. In three children a repeat sternotomy was avoided by implanting the atrial electrodes during the Fontan operation. All patients improved clinically, including resolution of PLE in four patients. Bradyarrhythmias may lead to significant morbidity after Fontan-type operations. Electrophysiological evaluation is advised at follow-up. The indication for implantation of a DDD pacemaker system should be liberal. Placing atrial electrodes during the Fontan operation, especially in the presence of a right ventricular anatomy, avoids repeat sternotomy.
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Affiliation(s)
- Markus K Heinemann
- Departments of Thoracic, Cardiac, and Vascular Surgery, University Hospital, Tübingen, Langenbeckstr. 1, # 505, 55131 Mainz, Germany.
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Ermis C, Zadeii G, Gupta M, Benditt DG. Trans-aortic His bundle ablation with permanent ventricular pacing via the coronary sinus in L-transposition of great arteries with classic Fontan procedure. J Interv Card Electrophysiol 2002; 7:257-60. [PMID: 12510138 DOI: 10.1023/a:1021397626467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We report findings in a patient with 1-transposition of great arteries with single ventricle and classic Fontan procedure who required both His bundle ablation for palliation of refractory atrial tachycardia and placement of a transvenous dual-chamber atrio-ventricular permanent pacemaker for hemodynamic support. A method for retrograde trans-aortic His bundle ablation in this congenital anomaly and subsequent placement of permanent dual chamber pacemaker using the right atrium and coronary sinus as an access to the ventricle is described.
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Affiliation(s)
- Cengiz Ermis
- Cardiac Arrhythmia Center, Department of Medicine (Cardiovascular Division), Minneapolis, Minnesota, USA
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35
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Cohen MI, Bush DM, Gaynor JW, Vetter VL, Tanel RE, Rhodes LA. Pediatric pacemaker infections: twenty years of experience. J Thorac Cardiovasc Surg 2002; 124:821-7. [PMID: 12324742 DOI: 10.1067/mtc.2002.123643] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We sought to evaluate possible predictors of early and late pacemaker infections in children. METHODS A review was performed of all pacemakers implanted in children at The Children's Hospital of Philadelphia between 1982 and 2001. Infections were classified as superficial cellulitus, deep pacemaker pocket infection necessitating removal, or positive blood culture without an identifiable source. RESULTS A total of 385 pacemakers (224 epicardial and 161 endocardial) were implanted in 267 patients at 8.4 +/- 6.2 years. All 2141 outpatient visits were reviewed (median follow-up, 29.4 months; range, 2-232 months). There were 30 (7.8%) pacemaker infections: 19 (4.9%) superficial infections; 9 (2.3%) pocket infections; and 2 (0.5%) isolated positive blood cultures. All superficial infections resolved with intravenous antibiotics. The median time from implantation to infection was 16 days (range, 2 days-5 years). Only 1 deep infection occurred after primary pacemaker implantation. Six patients with deep infections were pacemaker dependent and were successfully managed with intravenous antibiotics, followed by lead-generator removal and implantation of a new pacemaker in a remote location. In univariate analyses trisomy 21 (relative risk, 3.9; P <.01), pacemaker revisions (relative risk, 2.5; P <.01), and single-chamber devices (relative risk, 2.4; P <.05) were identified as predictors of infection. However, in multivariate analyses only trisomy 21 and pacemaker revisions were predictors. CONCLUSIONS The incidences of superficial and deep pacemaker infections were 4.9% and 2.3%, respectively. Trisomy 21 and pacemaker revisions were significant risk factors in the development of infection after pacemaker implantation. For primary pacemaker implantation, the risk of infection requiring system removal is low (0.3%).
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Affiliation(s)
- Mitchell I Cohen
- Division of Cardiology, Department of Pediatrics, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Powell AJ, Gauvreau K, Jenkins KJ, Blume ED, Mayer JE, Lock JE. Perioperative risk factors for development of protein-losing enteropathy following a Fontan procedure. Am J Cardiol 2001; 88:1206-9. [PMID: 11703976 DOI: 10.1016/s0002-9149(01)02066-5] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- A J Powell
- Department of Cardiology, Children's Hospital, Boston, Masschusetts 02115, USA.
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37
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Cohen MI, Vetter VL, Wernovsky G, Bush DM, Gaynor JW, Iyer VR, Spray TL, Tanel RE, Rhodes LA. Epicardial pacemaker implantation and follow-up in patients with a single ventricle after the Fontan operation. J Thorac Cardiovasc Surg 2001; 121:804-11. [PMID: 11279424 DOI: 10.1067/mtc.2001.113027] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES There is an increasing incidence of sinus node dysfunction after the Fontan procedure. Inability to maintain atrioventricular synchrony after the Fontan operation has been associated with an adverse late outcome. Although pacing may be helpful as a primary or adjunct modality after the Fontan procedure, the effects of performing a late thoracotomy or sternotomy for epicardial pacemaker implantation are unknown. In addition, little is known about the long-term effectiveness of epicardial leads in patients with single ventricles. The purpose of this study was to compare the hospital course and follow-up of epicardial pacing lead implantation in patients with Fontan physiology and patients with 2-ventricle physiology. METHODS We retrospectively reviewed all isolated epicardial pacemaker implantations and outpatient evaluations performed between January 1983 and June 2000. RESULTS There was no difference in the perioperative course for the 31 Fontan patients (27 atrial and 41 ventricular leads [68 total]) compared with the 56 non-Fontan subjects (9 atrial and 61 ventricular leads [70 total]). The median length of stay in Fontan and non-Fontan patients was 3 and 4 days, respectively. There was no early mortality in either group. Pleural drainage for 5 days or longer was reported in 4% of the Fontan cohort and 3% of the non-Fontan group. Late pleural effusions were identified in only 2 patients in the Fontan group and 2 patients in the non-Fontan group. There was no significant difference in epicardial lead survival between the Fontan group and the non-Fontan group (1 year, 96%; 2 years, 90%; 5 years, 70%). The overall incidence of lead failure was 17% (24/138). CONCLUSIONS Epicardial leads can be safely placed in Fontan patients at no additional risk compared to patients with biventricular physiology. Sensing and pacing qualities were relatively constant in both the Fontan and non-Fontan groups over the first 2 years after implantation.
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Affiliation(s)
- M I Cohen
- Divisions of Cardiology and Cardiothoracic Surgery, The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA.
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Valsangiacomo E, Molinari L, Rahn-Schönbeck M, Bauersfeld U. DDD pacing mode survival in children with a dual-chamber pacemaker. Ann Thorac Surg 2000; 70:1931-4. [PMID: 11156097 DOI: 10.1016/s0003-4975(00)01967-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The persistence of DDD pacing is well documented in adults, however, in children survival of the DDD pacing mode is less clear. METHODS We studied the survival of dual-chamber (DDD) pacing in 36 children aged 1 week to 16 years who underwent implantation of a dual-chamber pacing system between January 1986 and October 1998. The children were divided in the following two groups: 26 had epicardial pacing systems and 10 had endocardial pacing systems. RESULTS During long-term follow-up 11 patients lost the DDD pacing mode. The DDD pacing survival rate at 3 months and 1, 2, and 5 years was 80%, 77%, 73%, and 69%, respectively. Age, weight, congenital heart disease, and epicardial pacing leads were not found to be risk factors for loss of DDD pacing mode. However, P-wave values of less than 2.5 mV at implantation of epicardial leads were associated with loss of the DDD pacing mode. CONCLUSIONS The majority of children remain in the DDD pacing mode during long-term follow-up. A P-wave value of less than 2.5 mV at implantation of epicardial leads is a risk factor for loss of the DDD pacing mode.
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Affiliation(s)
- E Valsangiacomo
- University Children's Hospital, and Department of Cardiovascular Surgery, University Hospital, Zurich, Switzerland
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39
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Wernovsky G, Stiles KM, Gauvreau K, Gentles TL, duPlessis AJ, Bellinger DC, Walsh AZ, Burnett J, Jonas RA, Mayer JE, Newburger JW. Cognitive development after the Fontan operation. Circulation 2000; 102:883-9. [PMID: 10952957 DOI: 10.1161/01.cir.102.8.883] [Citation(s) in RCA: 208] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with a single ventricle have multiple risk factors for central nervous system injury, both before and after the Fontan procedure. METHODS AND RESULTS A geographically selected cohort was invited to undergo standardized testing, including age-appropriate measures of intelligence quotient (IQ) and achievement tests. Historical information was obtained by chart review and patient questionnaires. Of the 222 eligible patients, 133 (59.9%) participated. Median age at testing was 11.1 years (range, 3. 7 to 41.0 years), 6.0 years (range, 1.6 to 19.6 years) after surgery. Mean full-scale IQ was 95.7+/-17.4 (P<0.006 versus normal); 10 patients (7.8%) had full-scale IQ scores <70 (P=0.001). After adjustment for socioeconomic status, lower IQ was associated with the use of circulatory arrest before the Fontan operation (P=0.002), the anatomic diagnoses of hypoplastic left heart syndrome (P<0.001) and "other complex" (P=0.05), and prior placement of a pulmonary artery band (P=0.04). Mean composite achievement score was 91.6+/-15. 4 (P<0.001 versus normal); 14 patients (10.8%) scored <70 (P<0.001). After adjustment for socioeconomic status, independent risk factors for low achievement scores included the diagnoses of hypoplastic left heart syndrome (P=0.004) and "other complex" (P=0.003) or prior use of circulatory arrest (P=0.03), as well as a reoperation with cardiopulmonary bypass within 30 days of the Fontan (P=0.01). CONCLUSIONS Most individual patients palliated with the Fontan procedure in the 1970s and 1980s have cognitive outcome and academic function within the normal range, but the performance of the cohort is lower than that of the general population.
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Affiliation(s)
- G Wernovsky
- Department of Cardiology, Children's Hospital, Harvard Medical School, Boston, MA, USA.
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Ramesh V, Gaynor JW, Shah MJ, Wieand TS, Spray TL, Vetter VL, Rhodes LA. Comparison of left and right atrial epicardial pacing in patients with congenital heart disease. Ann Thorac Surg 1999; 68:2314-9. [PMID: 10617023 DOI: 10.1016/s0003-4975(99)01053-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Complex congenital heart disease (CHD) often necessitates the use of epicardial pacing. Adequate right atrial (RA) sensing and pacing thresholds are often difficult to obtain due to suture line scarring and RA dilatation. The purpose of this study was to evaluate the placement of left atrial (LA) epicardial leads in children. METHODS Patient demographics, pacing, and sensing data of atrial pacing systems implanted between January 1994 and January 1997 were collected. RESULTS Forty-nine pacing systems were implanted: 14 LA epicardial, 19 RA epicardial, and 16 transvenous in the right atrium. Lead impedance, current, and energy were similar in the two epicardial groups throughout the study. Energy thresholds (ET) were lower in the LA than RA at 6 months, and 1 and 2 years (p < 0.05). Analysis of post-Fontan patients performed alone revealed a lower ET in the LA as compared with the RA. Pacing and sensing parameters from transvenous leads are presented for relative comparison. CONCLUSIONS Transvenous leads are most efficient but often contraindicated in complex CHD. LA leads offer lower energy thresholds than RA leads with similar sensing parameters.
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Affiliation(s)
- V Ramesh
- Division of Cardiology, The Children's Hospital of Philadelphia, Pennsylvania 19104, USA
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41
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Gentles TL, Mayer JE, Gauvreau K, Newburger JW, Lock JE, Kupferschmid JP, Burnett J, Jonas RA, Castañeda AR, Wernovsky G. Fontan operation in five hundred consecutive patients: factors influencing early and late outcome. J Thorac Cardiovasc Surg 1997; 114:376-91. [PMID: 9305190 DOI: 10.1016/s0022-5223(97)70183-1] [Citation(s) in RCA: 400] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The purpose of this study was to review a large, evolving, single-center experience with the Fontan operation and to determine risk factors influencing early and late outcome. METHODS The first 500 patients undergoing modifications of the Fontan operation at our institution were identified. Perioperative variables were recorded and a cross-sectional review of survivors was undertaken. RESULTS The incidence of early failure decreased from 27.1% in the first quartile of the experience to 7.5% in the last quartile. In a multivariate model, the following variables were associated with an increased probability of early failure: a mean preoperative pulmonary artery pressure of 19 mm Hg or more (p < 0.001), younger age at operation (p = 0.001), heterotaxy syndrome (p = 0.03), a right-sided tricuspid valve as the only systemic atrioventricular valve (p = 0.001), pulmonary artery distortion (p = 0.04), an atriopulmonary connection originating at the right atrial body or appendage (p = 0.001), the absence of a baffle fenestration (p = 0.002), and longer cardiopulmonary bypass time (p = 0.001). An increased probability of late failure was associated with the presence of a pacemaker before the Fontan operation (p < 0.001). A morphologically left ventricle with normally related great arteries or a single right ventricle (excluding heterotaxy syndrome and hypoplastic left heart syndrome) were associated with a decreased probability of late failure (p = 0.003). CONCLUSIONS These analyses indicate that early failure has declined over the study period and that this decline is related in part to procedural modifications. A continuing late hazard phase is associated with few patient-related variables and does not appear related to procedural variables.
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Affiliation(s)
- T L Gentles
- Department of Cardiology, Children's Hospital, Boston, MA 02115, USA
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Gentles TL, Gauvreau K, Mayer JE, Fishberger SB, Burnett J, Colan SD, Newburger JW, Wernovsky G. Functional outcome after the Fontan operation: factors influencing late morbidity. J Thorac Cardiovasc Surg 1997; 114:392-403; discussion 404-5. [PMID: 9305191 DOI: 10.1016/s0022-5223(97)70184-3] [Citation(s) in RCA: 166] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The purpose of this study was to describe the functional outcome of a large number of patients after modifications of the Fontan operation and to investigate perioperative risk factors that might influence late functional state. METHODS A comprehensive cross-sectional review of the first 500 patients undergoing a Fontan operation at our institution was undertaken. Those surviving with an intact Fontan circulation were reviewed by questionnaire to assess functional status and medication history. Medical records, chest roentgenograms, echocardiograms, cardiac catheterizations, and laboratory investigations were also reviewed to assess postoperative status. RESULTS Three hundred sixty-three long-term survivors with an intact Fontan circulation were identified during cross-sectional follow-up. Median age at operation was 5.0 years (range 0.4 to 31 years), and median follow-up was 5.4 years (range 1.7 to 20 years). Most patients (91.1%) were in New York Heart Association class I or II. In a multivariate model, poor (class III or IV) functional state was associated with longer duration of follow-up (p < 0.001), a prior atrial septectomy (p = 0.03), and a prior main pulmonary artery-ascending aorta anastomosis (p = 0.05). CONCLUSIONS A poor functional outcome is uncommon after the Fontan operation but becomes more frequent with increasing duration of follow-up.
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Affiliation(s)
- T L Gentles
- Department of Cardiology, Children's Hospital, Boston, MA 02115, USA
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Seiden HS, Camuñas JL, Fishburger SB, Golinko RJ, Steinberg LG, Shagong U, Rossi AF. Use of single lead VDD pacing in children. Pacing Clin Electrophysiol 1997; 20:1967-74. [PMID: 9272535 DOI: 10.1111/j.1540-8159.1997.tb03603.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The development of transvenous ventricular pacing leads with proximal electrodes capable of atrial sensing and the recent availability of smaller generators has created the opportunity to treat children with complete AV block and normal sinus node function with a transvenous single lead VDD pacing system. Studies in adults have demonstrated this system to be efficacious with low complication rates. Transvenous single lead VDD pacemakers were implanted in ten children, aged 5-15 years, between December 1993 and April 1996, in our institution. The indications were complete AV block with severe bradycardia in 5 patients, second-degree or complete AV block following congenital heart surgery in 3, complete AV block with long QT syndrome in 1, and second-degree AV block and syncope in 1. There were no complications related to the procedure in any case. P and R wave amplitudes were measured and thresholds were determined intraoperatively on all patients. Amplitudes and thresholds were remeasured on seven patients with a mean follow-up of 17 months; Holter monitors were performed on seven patients with mean follow-up of 16 months. P and R wave amplitudes were generally diminished at follow-up compared to initial values but remained within an acceptable range for all patients. Four patients required reprogramming after pacemaker insertion, 1 received an atrial lead for dual chamber pacing, 1 required reposition for lead dislodgment, and 1 patient required a new lead for an inadequate ventricular pacing threshold. No patient had evidence of failure to sense or capture as evaluated by Holter monitoring at last follow-up. Single lead VDD pacing systems can be successfully used in properly selected children with high degree or complete AV block with normal sinus node function.
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Affiliation(s)
- H S Seiden
- Department of Pediatrics, Mount Sinai Medical Center, New York, New York 10029, USA
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Adwani SS, Sreeram N, DeGiovanni JV. Percutaneous transhepatic dual chamber pacing in children with Fontan circulation. HEART (BRITISH CARDIAC SOCIETY) 1997; 77:574-5. [PMID: 9227306 PMCID: PMC484805 DOI: 10.1136/hrt.77.6.574] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Permanent pacing is often required following the Fontan operation and is usually performed epicardially as there is no direct access to the ventricle from the systemic veins. Dual chamber endocardial pacing was achieved by the transhepatic approach in two children with Fontan circulation. The patients were a 7 year old boy with left atrial isomerism, single ventricle with pulmonary stenosis, interrupted inferior vena caval vein with azygous continuation, and direct drainage of the hepatic veins to the right sided atrium, and a 6 year old girl with tricuspid atresia. This approach to endocardial pacemaker implantation is potentially of considerable value in patients who do not have direct access to the ventricle from the systemic veins.
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Affiliation(s)
- S S Adwani
- Department of Cardiology, Birmingham Children's Hospital NHS Trust, United Kingdom
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