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J Thorac Cardiovasc Surg 2009;138:937-940
© 2009 The American Association for Thoracic Surgery

Congenital Heart Disease

Device management of arrhythmias after Fontan conversion

^a Division of Cardiology, Children's Memorial Hospital, Chicago, IIl
^b Division of Cardiovascular-Thoracic Surgery, Children's Memorial Hospital, Chicago, IIl
^c Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Ill
^d Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IIl
^e Center for Pediatric and Congenital Heart Diseases, Cleveland Clinic Children's Hospital, Cleveland Clinic Lerner School of Medicine, Case Western Reserve University, Cleveland, Ohio

Received for publication June 13, 2008; revisions received October 13, 2008; accepted for publication November 24, 2008.

^_* Address for reprints: Sabrina Tsao, MD, Division of Cardiology-M/C #21, Children's Memorial Hospital, 2300 Children's Plaza, Chicago, IL 60614. (Email: stsao{at}childrensmemorial.org).

Objectives: We assessed our pacemaker strategy, use of antitachycardia therapies, generator longevity, and need for programming changes in patients having Fontan conversion with arrhythmia surgery.

Methods: Between 1994 and 2008, of 121 consecutive patients having Fontan conversion and arrhythmia surgeries, 120 patients underwent pacemaker implantation at the time of Fontan conversion (mean age 22.9 ± 8.1 years). Prior pacemakers were in place in 32/120 (26.7%) patients. Between 1994 and 1998, single-chamber atrial antitachycardia pacemakers were implanted (n = 12); atrial rate-responsive pacemakers (n = 31) were implanted between 1998 and 2002. Dual-chamber rate-responsive pacemakers (n = 16) were used between 2002 and 2003, and subsequently dual-chamber antitachycardia pacemakers (n = 61) have become the pacemaker of choice. Leads have evolved from transatrial endocardial leads to epicardial unipolar and subsequently bipolar leads.

Results: Among 87 patients with adequate follow-up, all are currently atrially paced at a minimum lower rate 70 beats per minute. Single-chamber atrial pacemakers were implanted in 43 (antitachycardia in 12), and dual-chamber pacemakers in 77 (antitachycardia in 61); multisite ventricular leads were placed in 7 patients. Far-field R-wave sensing in 78.6% of unipolar atrial leads led to use of epicardial bipolar leads. Late atrioventricular block (24%) led to routine implantation of dual-chamber pacemakers. Antitachycardia pacing was utilized in 7%. One patient required acute lead revision and 4 required late upgrade to dual-chamber pacemakers. There was no pacemaker-related infection. Twenty patients required generator change, and the mean device longevity was 7.53 years.

Conclusions: Customized pacemaker therapy can optimize management of patients following Fontan conversion. Device longevity is excellent. Based on our experience with 120 Fontan conversions, we recommend placement of a dual-chamber antitachycardia pacemaker with bipolar steroid-eluting epicardial leads in all patients at the time of the conversion.