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Ann Thorac Surg 2004;78:202-203
© 2004 The Society of Thoracic Surgeons
Department of Cardiac Surgery, University Hospital of Ghent, 185, De Pintelaan, 9000 Ghent, Belgium
e-mail: thierry.bove{at}ugent.be
e-mail: katrien.francois{at}ugent.be
Despite technologic refinements, pacing in children with congenital heart disease remains a permanent source of inconvenience. These children have the life-long possibility of pacemaker-related complications such as lead and battery dysfunction, inadequacy of vascular access, and local or even systemic infection. Moreover, owing to the anatomical barriers of specific congenital malformations, some of these children will stay dependent on an epicardial pacing system.
In this study, Cohen and coworkers advocate the prophylactic use of epicardial leads at the time of surgical repair of the congenital heart disorder in a subset of children who are at risk for later bradyarrhythmias and so later pacemaker need, to avoid an additional thoracotomy or sternotomy.
Over a 10-year period, prophylactic epicardial leads were placed in 56 children, and later lead retrieval for definitive pacing was required in only 13 children (23%). They report a lead retrieval success of nearly 90%, with pacing variables similar to those of epicardial leads placed with concomitant generator implantation.
Furthermore, the advent of steroid-eluting leads has introduced a new era in epicardial pacing, resulting in stimulation and sensing thresholds and longevity, comparable to those of conventional endocardial leads [1]. The growing efficacy of these epicardial leads may encourage more extended use of prophylactic lead implantation for conditions in which later permanent pacing is supposed to be required. That may result in a number of unnecessary implants, exposing these patients possibly to the risk of unnecessary complications.
The main question to answer is, which patients would benefit the most from prophylactic epicardial lead placement? The occurrence of atrioventricular (AV) block or a history suggesting sinus node dysfunction are the most frequent clinical indications in Cohen's series.
Postoperative complete AV block will often lead to early definitive pacing, although late recovery of AV conduction is not unusual, with observations reporting late conduction restoration in 10% to 30% [2, 3]. Nonetheless, transient perioperative second- or third-degree AV block are not considered as an absolute indication for prophylactic epicardial lead insertion. Also, it has not yet been proved that early establishment of AV synchrony in children with normal biventricular function is more beneficial than the single-chamber VVIR pacing mode [4]. Additionally, a secondary sternotomy or thoracotomy can be avoided by a limited subxyphoid approach that affords sufficient access to the diaphragmatic side of the ventricle for single-chamber pacing together with the submuscular battery placement into the posterior rectus sheath. Hence, these patients are probably not candidates for the use of prophylactic epicardial pacing leads.
Consequently, the best-suited patients are children with a univentricular heart treated by the Fontan operation. Dual-chamber pacing and sensing may be more warranted in single ventricle physiology to optimize cardiac performance. Because of the limited access to the atrium, especially in case of an extraatrial repair, the implantation of atrial epicardial leads at the time of final surgery in patients with sinus node dysfunction will achieve the goal of this prophylactic approach, ie, avoiding later surgical reentry.
In conclusion, the efficacy of the epicardial leads has increased over time and makes them suitable for prophylactic use. However, clearer delineation of the clinical indication related to each individual child and the specific anatomical configuration must help to identify the appropriate indication, so a prophylactic approach will not result in an unnecessary procedure.
References
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