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J Thorac Cardiovasc Surg 2001;121:804-811
© 2001 The American Association for Thoracic Surgery

Surgery for Congenital Heart Disease

Epicardial pacemaker implantation and follow-up in patients with a single ventricle after the Fontan operation

From the Divisions of Cardiology^a and Cardiothoracic Surgery^b and The Departments of Pediatrics and Surgery, The Children's Hospital of Philadelphia and The University of Pennsylvania School of Medicine, Philadelphia, Pa.

Presented in part at the 73rd Scientific Sessions of the American Heart Association, New Orleans, La, November 2000.

Received for publication Sept 13, 2000. Revisions requested Oct 25, 2000; revisions received Nov 10, 2000. Accepted for publication Nov 16, 2000. Address for reprints: Mitchell I. Cohen, MD, Division of Pediatric Cardiology, The Children's Hospital of Philadelphia, 34th & Civic Center Boulevard, Philadelphia, PA 19104 (E-mail: cohenmi{at}email.chop.edu).

Abstract

Objectives: There is an increasing incidence of sinus node dysfunction after the Fontan procedure. Inability to maintain atrioventricular synchrony after the Fontan operation has been associated with an adverse late outcome. Although pacing may be helpful as a primary or adjunct modality after the Fontan procedure, the effects of performing a late thoracotomy or sternotomy for epicardial pacemaker implantation are unknown. In addition, little is known about the long-term effectiveness of epicardial leads in patients with single ventricles. The purpose of this study was to compare the hospital course and follow-up of epicardial pacing lead implantation in patients with Fontan physiology and patients with 2-ventricle physiology.
Methods: We retrospectively reviewed all isolated epicardial pacemaker implantations and outpatient evaluations performed between January 1983 and June 2000.
Results: There was no difference in the perioperative course for the 31 Fontan patients (27 atrial and 41 ventricular leads [68 total]) compared with the 56 non-Fontan subjects (9 atrial and 61 ventricular leads [70 total]). The median length of stay in Fontan and non-Fontan patients was 3 and 4 days, respectively. There was no early mortality in either group. Pleural drainage for 5 days or longer was reported in 4% of the Fontan cohort and 3% of the non-Fontan group. Late pleural effusions were identified in only 2 patients in the Fontan group and 2 patients in the non-Fontan group. There was no significant difference in epicardial lead survival between the Fontan group and the non-Fontan group (1 year, 96%; 2 years, 90%; 5 years, 70%). The overall incidence of lead failure was 17% (24/138).
Conclusions: Epicardial leads can be safely placed in Fontan patients at no additional risk compared to patients with biventricular physiology. Sensing and pacing qualities were relatively constant in both the Fontan and non-Fontan groups over the first 2 years after implantation.

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