Permanent Atrial Pacing Lead Implant Route after Fontan Operation

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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 μJ, P = 0.049), but similar at follow-up (1.2 vs 2.6 μJ, 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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