Permanent Transvenous Atrial Pacing in Patients with an Intracardiac Fontan's Tunnel

Objectives: Pacemaker implantation is not uncommon in patients after Fontan's surgery, frequently due to sinus node dysfunction (up to 23% in the literature). If atrial stimulation is required and resternotomy should be avoided, transvenous placing of an atrial lead could be an option, considering an effective anticoagulation. However, proper lead placement is challenging because of the electrophysiological conditions inside the tunnel and the risk for early lead dislodgement. We report two patients who successfully received an upgrade from a preexisting epimyocardial VVI-pacemaker system to a DDD system by using a special transvenous lead system.

Methods: Our first male patient was born with pulmonary atresia with intact ventricular septum. He received an epimyocardial DDD-pacemaker system almost 2 years after total cavopulmonary anastomosis (TCPC). At the age of 27 years, he presented with atrial fibrillation and an empty pacemaker battery. During pacemaker replacement, dysfunction of the preexisting epimyocardial atrial lead was diagnosed and decision for transvenous atrial lead implantation was made. Implantation procedure turned out to be difficult because of problems to fix a standard lead inside the tunnel system. Unfortunately, postoperative check-up at 4 weeks later revealed lead dislodgement. For the second attempt, we used a special lead system with a 4.1-Fr active-fixation lead and a steerable catheter. Implantation of the new lead was uneventful, postoperative follow-up (>6 months) revealed regular lead position and good testing values (threshold and sensing). The second female patient suffered from tricuspid atresia with a hypoplastic right ventricle. Eight months after TCPC, an epimyocardial VVI-pacemaker system was implanted due to pauses in the Holter ECG. To restore AV synchronicity and improve hemodynamics, an upgrade to a DDD system at the age of 15 years was necessary. Procedure with the 4.1-Fr lead, and steerable catheter system could be performed rapidly and follow-up (>6 months) was uneventful with good pacing threshold and sensing.

Conclusion: In our experience (with only few patients up to now), the use of a special lead system with a steerable catheter could facilitate transvenous lead placement inside an intracardiac Fontan's tunnel. A reduced risk for early lead dislodgement (and therefore reintervention), as well as good pacing thresholds, appear to be most beneficial to us.

Publication History

Article published online:
21 February 2021