25 Years of Experience in Pediatric Pacing: Is There an Achilles Heel?

Objective: Perioperative and postoperative data of all pediatric patients undergoing pacemaker procedures in Sana Heart Center in Stuttgart were analyzed retrospectively.

Methods: Between December 1991 and September 2016, a total of 120 patients (mean age, 5.4 ± 5.39, range, 1 day-18 years; mean body weight 20.0± 18.6, range, 2.45–104 kg) underwent 219 pacemaker related procedures in a single center. Procedures performed were the first implantation of an epicardial (n = 84, 70%) or a transvenous (n = 36, 30%) pacemaker system. Indications for a permanent pacemaker implantation were congenital atrio-ventricular block in 31 patients or acquired atrioventricular block in 13 patients. Atrio-ventricular block following surgery for congenital heart disease appeared in 53 patients either early after operation (67%) or in the long-term follow up (33%). A sinus node dysfunction was an indication for a pacemaker implantation in 18 patients. Total follow-up was 1413 years; mean 9.6 ± 5.3 (epicardial) and 14.5 ± 6.9 (transvenous).

Results: There were no pacemaker related deaths and no major complications following surgery for pacemaker procedures. Reoperation rates for battery change, lead procedure, complete system change or any other reason for a reoperation were not significantly different (log rank test, p > 0.14) between the epicardial and the transvenous pacemaker group. A multivariable analysis regarding the risk of reoperation indicated lower weight as the only significant risk factor for reoperation (p = 0.014, HR = 0.975). Twenty-nine children weighted less than 10kg at primary implantation and were all treated with an epicardial pacemaker system. Generator size and lead length are still a challenge in small children. Children with weight less than 30 kg were preferably (p < 0.001) treated with epicardial pacing (55 of 62 patients, 87.5%). Those weighing more than 30 kg were treated either with epicardial pacing (7 patients, 36.6%) or with transvenous pacing (12 patients, 63.2%). The youngest patient treated with a transvenous system was 13 months and weighted 11kg.

Conclusion: Pacemaker implantation in children is a safe procedure regardless if the implantation is epicardial or transvenous. But pacemaker related reoperations are common and especially young patients need regular reinterventions. As technical development of pacemaker systems remains stable, alternative strategies for children as well as for adults requiring pacemaker implantation should be encouraged.