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Ann Thorac Surg 2008;85:1704-1711. doi:10.1016/j.athoracsur.2008.02.016
© 2008 The Society of Thoracic Surgeons
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Right arrow Electrophysiology - arrhythmias

Original Articles: Pediatric Cardiac

A 12-Year Experience of Bipolar Steroid-Eluting Epicardial Pacing Leads in Children

Maren Tomaske, MDa,*, Bart Gerritse, PhDc, Leo Kretzers, MSc, Rene Pretre, MDb, Ali Dodge-Khatami, MD, PhDb, Mariette Rahn, MDb, Urs Bauersfeld, MDa

a Division of Pediatric Cardiology, University Children's Hospital, Zurich, Switzerland
b Division of Congenital Cardiovascular Surgery, University Children's Hospital, Zurich, Switzerland
c Medtronic Bakken Research Center, Maastricht, the Netherlands

Accepted for publication February 6, 2008.

* Address correspondence to Dr Tomaske, Division of Pediatric Cardiology, University Children's Hospital, Steinwiesstrasse 75, Zurich, 8032, Switzerland (Email: maren.tomaske{at}kispi.uzh.ch).


Dr Bauersfeld, Dr Gerritse, and Mr Kretzers disclose that they have a financial relationship with Medtronic Inc.

 

   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: Cardiovascular abnormalities and small vascular size may preclude transvenous pacing and necessitate epicardial lead implantation. This study evaluates the performance of steroid-eluting, bipolar epicardial pacing leads.

Methods: We prospectively enrolled 114 children with 239 atrial and ventricular bipolar epicardial leads (Medtronic CapSure 10366 or 4968, Minneapolis, MN), followed up to 12.2 years (median, 3.2). Lead data were obtained at implant and at semi-annual visits. Analysis was done for left or right atrial and ventricular leads.

Results: Median atrial and ventricular pacing thresholds remained below 1.2 V at 0.5 ms. Thresholds did not differ between pacing sites: left atrial, 0.82V at 0.5 ms; right atrial, 0.74 V at 0.5 ms (p = 0.85); and left ventricular, 0.96V at 0.5 ms; right ventricular, 0.94 V at 0.5 ms (p = 0.65). Sensing demonstrated no difference for atrial leads, at left atrial, 3.4 mV; and right atrial, 2.9 mV (p = 0.12), but there was superiority of left over right ventricular leads (11.2 vs 7.7 mV, p = 0.002). During follow-up, the 239 atrial and ventricular leads experienced 19 (8%) lead failures. Lead survival at 2 and 5 years was 99% and 94% for atrial leads and 96% and 85% for ventricular leads, respectively.

Conclusions: Bipolar steroid-eluting epicardial leads demonstrate excellent sensing characteristics and persistent low median pacing thresholds below 1.2 V at 0.5 ms in children during up to 12 years follow-up. Considering growing and active patients with most having congenital heart disease, the lead survival of 85% to 94% at 5 years is favorable. Subanalysis shows superior sensing for left ventricular leads. Bipolar steroid-eluting leads provide an alternative approach for permanent pacing and may also be considered for left atrial and ventricular pacing, resynchronization, or defibrillator therapy.

Advances in lead and device technology allow pacemaker system implantation in infants and even in neonates [1, 2]. Besides bradycardia pacing for sinus node disease or heart block, resynchronization therapy and implantation of cardioverter defibrillators (ICD) are progressively more often required in pediatric patients and adults with congenital heart disease (CHD) [3].

Specific problems in children or adults with complex CHD can complicate pacemaker therapy. Small vessel size, cardiovascular abnormalities, or the intention to preserve the venous access often preclude a transvenous approach and require epicardial pacing [4, 5]. Moreover, physical activity and somatic growth may affect lead longevity in young patients [5–7].

Studies in the pediatric population have indicated superior longevity of transvenous over unipolar screw-in epicardial leads, mainly due to high thresholds, exit blocks, and fractures of epicardial leads [8]. Initial experiences with bipolar steroid-eluting epicardial leads have shown low pacing thresholds up to 18 months of follow-up [9].

A main disadvantage of transvenous leads is attributable to right ventricular (RV) pacing leading to impaired left ventricular (LV) systolic function over time [10]. The advantage of epicardial leads facilitating LV pacing and sensing has promoted further epicardial lead implantation for single-site LV pacing, resynchronization therapy, ICD therapy, or patients with a diseased RV [3]. The aim of this study was to evaluate pacing and sensing characteristics, and survival of bipolar steroid-eluting epicardial pacing leads in pediatric patients.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Study Patients and Leads
All children who received permanent pacing systems consisting of bipolar steroid-eluting epicardial leads (Medtronic CapSure Epi 10366 or 4968, Medtronic, Inc, Minneapolis, MN) between 1994 and 2006 were prospectively enrolled into the study. The study population comprised 114 patients with a maximum follow-up of 12.2 years. A total of 107 atrial and 132 ventricular pacing leads were implanted, including lead replacements or biventricular pacing in some patients. The choice for epicardial pacing systems was determined by patient size, cardiovascular abnormality, indication for pacing, and patient preference. Leads were connected to various single- and dual-chamber devices, biventricular devices, or ICDs. The study excluded 5 children: 3 died in-hospital due to a non-pacing-related cause and 2 children with leads not connected to a device.

The bipolar steroid-eluting epicardial leads have platinized, porous electrode surfaces with a surface area of 14 mm2 (anode) and 6 mm2 (cathode). They contain 1.0 mg or less of dexamethasone sodium phosphate. This study protocol was performed with institutional Ethical Committee approval and written informed consent.

Implant Data, Pacemaker Telemetry Data, and Lead Failures
For all leads, impedances, P- or R-wave amplitudes, as well as pacing voltage and energy thresholds were obtained at implant, at discharge, and regular follow-up visits. The first follow-up after discharge was within 4 to 6 weeks. Further follow-up was scheduled 3 months after implant and every 6 months thereafter. Pacing voltage and energy of lead thresholds were calculated for a standard value of 0.5-ms pulse duration (V at 0.5 ms and µJ at 0.5 ms) to allow for comparison by using the energy formula published previously [11]. In those patients in whom impedance measurements were unipolar, the difference between unipolar and bipolar measurements was noted once and added to the unipolar measurements during follow-up.

Lead events were grouped in two categories:

1 lead failure, which was defined as lead fracture, insulation defect, replacement due to unacceptably high thresholds or sensing abnormalities, loss of capture, lead dislodgement, or primary infection; and
2 secondary lead replacement, which was defined as events of secondary infection if leads were exposed to pocket infection, accidental lead damage at cardiopulmonary bypass surgery, or elective lead replacement at the time of device exchange.

Lead lifetime was defined as time elapsed from lead implant to the event of lead failure. From the date of exchange, new leads were enrolled as new implants with lead measurements starting at implant.

Performances of left (LA) and right atrial (RA) and LV and RV pacing leads, as well as the effect of prior cardiac operation, were also analyzed and compared.

Surgical Technique
Access for lead implantation was either by a subxiphoid incision to reach the RV apex or by a left lateral thoracotomy to reach the LV free wall and corresponding atria, as described previously [12]. In those children with concomitant cardiac procedures, the epicardial leads were implanted through a midline sternotomy at the time of cardiac operation, with preference of an LV implant site.

Standard surgical implant techniques were used with nonabsorbable sutures. For the distal and proximal suture of the triangular electrode, a single-knot technique was used. Sutures were placed perpendicularly to the epicardium to avoid tissue trauma near the electrode. The device was implanted in the abdominal rectus sheath in 46 patients, in a left thoracic muscular pocket in 66, or subpectorally in 2.

Statistical Analysis
A follow-up period of 8 years was statistically analyzed. Data are presented as median and interquartile (IQR) range. A value of p < 0.05 was considered statistically significant.

Survival is reported with Kaplan-Meier estimates and 95% confidence intervals (CI) and compared with a log-rank test. Electrical measurements were compared using linear regression models, with parameter estimation, corrected for multiple observations per patient, using generalized estimating equations. To determine individual change, regression slope coefficients over individual repeated measurements were calculated for each patient's course. Changes per year were calculated for each electrical parameter. To focus on the long-term changes, data collection for calculating regression slope coefficients was started 6 months after implant, with a minimum of 5 contributing measurements.

Correlations between variables were measured by the Spearman correlation. Mann-Whitney U tests were used for analyzing differences in continuous variables between independent groups. The Wilcoxon signed rank test was used for within-group changes of continuous variables between different time periods. The {chi}2 test provided a comparison of the pacing site as well as the effect of cardiac operation. All statistical analyses were performed using SAS 9.1 software (SAS Institute Inc, Cary, NC).


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
Patient Data
Demographic and surgical data as well as clinical characteristics at implantation are reported in Table 1. In 65% of the children, pacemaker system implantation was related to CHD with prior or concomitant cardiac operation. Six children were lost to follow-up at a median of 2.5 years. No deaths related to the pacemaker system occurred. Kaplan-Meier estimates of patient survival at 2, 5, and 10 years after enrolment were 98% (95% CI, 95% to 100%), 95% (95% CI, 90% to 100%), and 95% (95% CI, 83% to 100%), respectively.


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  		Table 1 Baseline Characteristics of 114 Children at First Epicardial Lead Implant
 
Lead Follow-Up and Performance
Follow-up consisted of 1251 visits contributing to atrial measurements and 1677 to ventricular lead measurements. Median follow-up time was 2.6 years (range, 0.1 to 11.7 years) for atrial leads and 2.8 years (range, 0.1 to 12.2 years) for ventricular leads. Lead characteristics are given in detail up to 10 years (Table 2). Median pacing voltage thresholds for atrial and ventricular leads remained below 1.2 V at 0.5 ms during the entire observation period. Median individual regression slopes indicated stable trends during follow-up for sensing (atrial, 0.000 [p = 0.88]; ventricular, 0.000 [p = 0.22]), pacing thresholds (atrial, 0.000 [p = 0.98], ventricular, 0.022 [p = 0.98]), and impedances (atrial, 8.135 [p = 0.39]; ventricular, 0.625 [p = 0.13]). Neither of the individual regression slopes for measured electrical parameters correlated with lead age at study closure (Table 3).


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  		Table 2 Measured Pacemaker Telemetry Data at Discharge and at Follow-Up
 

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  		Table 3 Spearman Correlation for Individual Regression Slopes of Measured Telemetry Data and Lead Age
 
A separate analysis of individual regression slopes was done for 13 atrial leads and 25 ventricular leads with a lead age older than 5 years (median, 9.4 years; range, 6.1 to 12.2 years). Comparison of individual regression slopes before and after a lead age of 5 years revealed no significant differences for atrial leads. For ventricular leads, a significant decline of impedances as well as a slight but not significant incline of pacing voltage thresholds was observed for measurements beyond 5 years (Fig 1).


Figure 1
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  		Fig 1. Subanalysis of 25 ventricular pacing leads with a lead age older than 5 years. Box and whisker plots of individual regression slopes demonstrated a slight incline of ventricular pacing voltage thresholds (A) for measurements beyond 5 years (median, –0.017 vs 0.052, p = 0.131). Measurements of ventricular impedances (B) significantly declined beyond 5 years (median, 5.53 vs –11.20, p = 0.003). The asterisk (*) denotes significance. The horizontal line in the middle of each box indicates the median; the top and bottom borders of the box mark the 75th and 25th interquartile, respectively. The whiskers mark is 97.5th and 2.5th percentile.

 
Analysis of lead performances between right or left atrial and ventricular implant sites demonstrated no difference between pacing voltage thresholds over time (Fig 2A, B). Moreover, no difference was seen in median P-wave amplitudes (LA, 3.4 mV vs RA, 2.9 mV; p = 0.12). However, a significantly superior course of ventricular sensing was seen for LV compared with RV leads (LV, 11.2 mV vs RV, 7.7 mV; p = 0.002).


Figure 2
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  		Fig 2. (A) Atrial and (B) ventricular pacing voltage thresholds at 0.5-ms pulse duration over time. No differences were found for median pacing voltages for (A) the right atrial (RA, diamonds) or left atrial (LA, squares) leads (LA, 0.82 V at 0.5 ms vs RA, 0.74 V at 0.5 ms; p = 0.85, or for the (B) right ventricular (RV, diamonds) or left ventricular (LV, squares) leads (LV, 0.96 V at 0.5 ms vs RV, 0.94 V at 0.5 ms; p = 0.65).

 
Analysis of the effect of prior or no cardiac operation revealed no difference for atrial (0.87 vs 0.67 V at 0.5 ms; p = 0.56) or ventricular pacing thresholds (1.01 vs 0.83 V at 0.5 ms; p = 0.21). No difference of prior or no cardiac operation was observed for P-wave (3.0 vs 3.3 mV; p = 0.31) or R-wave amplitudes (10.7 vs 9.0 mV; p = 0.57), respectively. Moreover, no significant differences for lead impedances or pacing energy thresholds were observed for the pacing sites and children with prior or no cardiac operation.

Lead Failures
During follow-up, 239 atrial and ventricular leads experienced 19 lead failures (8%). Characteristics of observed lead failures and secondary lead replacements are reported in Table 4.


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  		Table 4 Lead Failures and Secondary Lead Replacements During Follow-up, Categorized for Lead Position
 
At 2 and 5 years after implantation, the estimated freedom from lead failure was 99% (95% CI, 97% to 100%) and 94% (95% CI, 85% to 100%) for atrial leads, respectively; and was 96% (95% CI, 92% to 100%) and 85% (95% CI, 76% to 94%), respectively, for ventricular leads. Furthermore, estimated lead survival was compared by sites, and no statistical significance was found between left and right implant sites (Fig 3A, B).


Figure 3
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  		Fig 3. Kaplan-Meier estimates for lead survival of (A) 107 atrial and (B) 132 ventricular leads. (A) No difference was found between atrial pacing sites (p = 0.37). At 2 and 5 years, lead survival for right atrial (RA, dashed line) leads was 97% (95% confidence [CI], 90% to 100%) and 91% (95% CI, 75% to 100%), respectively; for left atrial (LA, solid line) leads it was 100% (95% CI, 100% to 100%) and 94% (95% CI, 83% to 100%), respectively. (B) No difference was found between ventricular pacing sites (p = 0.92). At 2 and 5 years, lead survival for right ventricle (RV, dotted line) leads was 100% (95% CI, 100% to 100%) and 84% (95% CI, 66% to 99%), respectively; for left ventricle (LV, solid line) leads it was 93% (95% CI, 85% to 100%) and 86% (95% CI, 75% to 97%), respectively.

 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Lead Performance and Survival
Recent advances in pacing lead technology, such as thin steroid-eluting transvenous leads, facilitate implantation even in neonates and infants, thus maintaining the controversy about the use of transvenous or epicardial pacing leads [13].

The main concerns for transvenous RV pacing leads in children are venous obstructions [13], lead failures due to somatic growth [5], lead infections [14], and the risk of paradoxic embolism in the presence of residual intracardiac defects [15]. Major drawbacks of older epicardial pacing leads have been the occurrence of lead fractures [16], increasing pacing thresholds over time [8, 16], and high pacing thresholds in children with prior cardiac operation [17]. The invention of steroid-eluting electrode surfaces combined with suture-on electrode tip designs has improved the epicardial lead performance [18, 19]. However, the potential advantage of the epicardial pacing system has yet to be demonstrated by prolonged experiences.

The present study enrolled 114 children after implantation of 107 atrial and 132 ventricular bipolar steroid-eluting epicardial pacing leads. Stable chronic atrial and ventricular sensing as well as pacing thresholds were achieved over a maximum follow-up of 12.2 years. Persistent low thresholds of steroid-eluting leads have been demonstrated for up to 6 years for unipolar epicardial leads [19, 20] and up to 7 years for transvenous leads [5, 7]. Similar to previous results of unipolar epicardial leads [19, 20], low median pacing thresholds of 1.2 V at 0.5 ms for atrial as well as ventricular leads were observed during follow-up in our study cohort, independently of the implant site. Recently, long-term pacing thresholds of transvenous leads in children have been reported to be slightly superior, ranging from 0.6 to 0.9 V at 0.5 ms [7, 8]. However, the number of children with prior cardiac operation and thereby higher risk for a diseased myocardium was smaller compared with our study cohort.

Epicardial lead failures occurred in 8% of the leads, with lead fractures and high thresholds being the most common complication. These findings are in line with results of recent studies reporting predominantly sutured-on epicardial leads [7, 19]. Comparably, the incidence of lead failures of modern transvenous leads in children is reported to be about 7% [7, 8]. The estimated 5-year lead survival seen in our cohort was 94% for atrial and 85% for ventricular pacing leads, independently of the implant site. These encouraging results of improved lead longevity confirm previous published data reporting of an estimated 5-year survival of 71% to 85% for epicardial leads [6, 7, 18]. Moreover, they are comparable with the survival of transvenous leads, with a reported estimated 5-year survival rate of 84% to 89% [6, 7].

Our favorable results of consistently low sensing and pacing thresholds, and improved lead longevity, were observed in a study designed with uniform use of a single technology and single manufacturer of epicardial pacing leads, followed up in a relatively large population of 114 children. Studies in children with permanent pacing usually have a small sample size. Previous reports of long-term experiences with epicardial lead thresholds and performance in large pediatric cohorts bear the limitation of showing performances of a variety of manufacturers, models, and technologies [5–8, 16]. The current study indicates improved long-term lead performance of bipolar steroid-eluting epicardial leads. Especially when connected to threshold tracking devices, low pacing thresholds will allow low energy pacing, resulting in a marked battery service life extension [21].

Steroid Elution
Steroid elution helps to diminish the initial inflammation after lead implant; however, a secondary intention is its effect on reducing stimulation thresholds over time. The question of how long steroid-eluting electrodes are capable of maintaining their steroid-eluting effect to prevent inflammation and fibrosis at the electrode-tissue interface is not satisfactorily answered. An experimental study [22] analyzed the remaining steroid in 25 transvenous explanted leads and demonstrated that 20% of the steroid was still present at 10 years. Remarkably, individual regression slopes indicated stable trends for telemetry data during the whole observation period and did not correlate with lead age. A separate analysis of those leads older than 5 years revealed stable lead performances for atrial leads and a slight incline for ventricular pacing voltages for measurements beyond a lead age of 5 years. Nevertheless, there was a significant decline of ventricular impedances measured beyond 5 years. A fast conducting interface between the electrode and epicardial surface due to a decrease of the steroid-eluting potency of the electrode, such as local edema or a deterioration of the lead insulation, could be a possible cause for the observed lower ventricular impedances over time. However, the restricted number of patients with a lead age older than 5 years limits the statistical validity of a conclusive statement.

Lead Implant Site
Clinical trials with permanent RV apex pacing have demonstrated asynchronous ventricular activation, leading to LV dysfunction over time [10]. Alternate pacing sites have been intensively studied, indicating a superior LV systolic function in children paced from the LV apex [23, 24]. The potential prevention of myocardial deterioration has led to a favored LV approach for lead placement in our study cohort. An important finding was a superior performance of ventricular sensing was seen for LV leads in our study cohort, whereas atrial sensing as well as atrial and ventricular pacing thresholds were independent of the implant site. Moreover, sensing and pacing characteristics of the epicardial leads were independent of prior cardiac operation.

Potential Clinical Implications
The LV systolic function is less adversely affected from LV pacing. Because epicardial pacing of the LV seems feasible and safe, it could be the preferred approach for ventricular pacing lead insertions. Furthermore, resynchronization therapy could be achieved by means of epicardial LV instead of transvenous pacing by way of the coronary sinus [25] in grown-ups with CHD. In addition to the favored LV position of the ventricular lead, a LA lead may be preferable after extensive RA surgery such as after Mustard, Fontan, or Ebstein anomaly surgery. Even though epicardial pacing lead placement inevitably involves a thoracotomy, LV pacing can easily be achieved by a minithoracotomy. A muscle-sparing minileft axillary approach is used in our institution, as published recently [12]. This technique was associated with a low complication rate and provides excellent cosmetic and functional results. Moreover, with the superior course for LV sensing, epicardial leads can safely be used in patients with ICD systems connected to epicardial sensing and pacing leads, and a subpleural defibrillation electrode [26].

Study Limitations
A main limitation of this study is the use of different devices. In the clinical setting, we observed slightly different threshold measurements between the devices. In addition, the variable of R-wave measurements changed over time. The new generations of devices do not offer the possibility to accurately determine R-wave sensing above 12.5 mV. This circumstance could, potentially, even have led to an underestimation of the superiority of R-wave sensing of LV leads.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Villain E, Martelli H, Bonnet D, Iserin L, Butera G, Kachaner J. Characteristics and results of epicardial pacing in neonates and infants Pacing Clin Electrophysiol 2000;23:2052-2056.[Medline]
  2. Aellig NC, Balmer C, Dodge-Khatami A, Rahn M, Prêtre R, Bauersfeld U. Long-term follow-up after pacemaker implantation in neonates and infants Ann Thorac Surg 2007;83:1420-1423.[Abstract/Free Full Text]
  3. Walsh EP, Cecchin F. Recent advances in pacemaker and implantable defibrillator therapy for young patients Curr Opin Cardiol 2004;19:91-96.[Medline]
  4. Dodge-Khatami A, Johnsrude CL, Backer CL, Deal BJ, Strasberger J, Mavroudis C. A comparison of steroid-eluting epicardial versus transvenous pacing leads in children J Card Surg 2000;15:323-329.[Medline]
  5. Silvetti MS, Drago F, Grutter G, De Santis A, Di Ciommo V, Rava L. Twenty years of paediatric cardiac pacing: 515 pacemakers and 480 leads implanted in 292 patients Europace 2006;8:530-536.[Abstract/Free Full Text]
  6. Fortescue EB, Berul CI, Cecchin F, Walsh EP, Triedman JK, Alexander ME. Patient, procedural, and hardware factors associated with pacemaker lead failure in paediatrics and congenital heart disease Heart Rhythm 2004;1:150-159.[Medline]
  7. Fortescue EB, Berul CI, Cecchin F, Walsh EP, Triedman JK, Alexander ME. Comparison of modern steroid-eluting epicardial and thin transvenous pacemaker leads in paediatrics and congenital heart disease patients J Intervent Cardiac Electrophysiol 2005;14:27-36.[Medline]
  8. Udink ten Cate F, Breur J, Boramanand N, et al. Endocardial and epicardial steroid lead pacing in the neonatal and paediatric age group Heart 2002;88:392-396.[Abstract/Free Full Text]
  9. Bauersfeld U, Nowak B, Molinari L, et al. Low energy epicardial pacing in children: the benefit of Autocapture Ann Thorac Surg 1999;68:1380-1383.[Abstract/Free Full Text]
  10. Tantengco MV, Thomas RL, Karpawich PP. Left ventricular dysfunction after long-term right ventricular apical pacing in the young J Am Coll Cardiol 2001;37:2093-2100.[Abstract/Free Full Text]
  11. Hamilton RM, Chiu C, Gow RM, Williams WG. A comparison of two stab-on unipolar epicardial leads in children Pacing Clin Electrophysiol 1997;20:631-636.[Medline]
  12. Dodge-Khatami A, Kadner A, Dave H, Rahn M, Prêtre R, Bauersfeld U. Left heart atrial and ventricular pacing through a left lateral thoracotomy in children: a safe approach with excellent functional and cosmetic results Eur J Cardio Thoracic Surg 2005;28:541-545.
  13. Ayabakan C, Rosenthal E. Endocardial pacemaker implantation in neonates and infants Indian Pacing Electrophysiol J 2006;6:57-62.[Medline]
  14. Klug D, Vaksmann G, Jarwe M, et al. Pacemaker lead infection in young patients Pacing Clin Electrophysiol 2003;26:1489-1493.[Medline]
  15. Khairy P, Landzberg MJ, Gatzoulis MA, et al. Epicardial versus endocardial pacing and thromboembolic events investigators: Transvenous pacing leads and systemic thromboemboli in patients with intracardiac shunts: a multicenter study Circulation 2006;113:2391-2397.[Abstract/Free Full Text]
  16. Cohen MI, Bush DM, Vetter VL, et al. Permanent epicardial pacing in paediatric patients: Seventeen Years of experience and 1200 outpatient visits Circulation 2001;29:2585-2590.
  17. Karpawich PP, Walter H, Hakimi M. Chronic performance of a transvenous steroid pacing lead used as epi-myocardial electrode Pacing Clin Electrophysiol 1998;21:1486-1488.[Medline]
  18. Ector B, Willems R, Heidbüchel H, et al. Epicardial pacing: a single-centre study on 321 leads in 138 patients Acta Cardiol 2006;61:343-351.[Medline]
  19. Cutler NG, Karpawich PP, Cavitt D, Hakimi M, Walters HL. Steroid-eluting epicardial pacing electrodes: six-year experience of pacing thresholds in a growing paediatric population Pacing Clin Electrophysiol 1997;20:2943-2948.[Medline]
  20. Horenstein MS, Hakimi M, Walters HL, Karpawich PP. Chronic performance of steroid-eluting epicardial leads in a growing pediatric population: a 10-year comparison Pacing Clin Electrophysiol 2003;26:1467-1471.[Medline]
  21. Tomaske M, Harpes P, Pretre R, Dodge-Khatami A, Bauersfeld U. Long-term experience with AutoCapture-controlled epicardial pacing in children Europace 2007;9:645-650.[Abstract/Free Full Text]
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  23. Vanagt WY, Verbeek XA, Delhaas T, Mertens L, Daenen WJ, Prinzen FW. The left ventricular apex is the optimal site for paediatric pacing: correlation with animal experience Pacing Clin Electrophysiol 2004;27:837-843.[Medline]
  24. Vanagt WY, Verbeek XA, Delhaas T, et al. Acute hemodynamic benefit of left ventricular apex pacing in children Ann Thorac Surg 2005;79:932-936.[Abstract/Free Full Text]
  25. Nothroff J, Norozi K, Arnhold JO, Wessel A, Ruschewski W, Buchhorn R. Pacemaker implantation as a risk factor for heart failure in young adults with congenital heart disease Pacing Clin Electrophysiol 2006;29:386-392.[Medline]
  26. Bauersfeld U, Tomaske M, Dodge-Khatami A, Rahn M, Kellenberger C, Pretre R. Initial experience with Implantable Cardioverter Defibrillator Systems using epicardial and pleural electrodes in paediatric patients Ann Thorac Surg 2007;84:303-305.[Abstract/Free Full Text]



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