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This study was undertaken to assess the incidence, indications, and predisposing factors for pacemaker placement in a pediatric heart transplant population. From November 1985 to May 1994, 246 pediatric patients have undergone cardiac transplantation at Loma Linda University Medical Center. Seven (2.8%) have received pacemaker placement with an 8-50 month follow-up period. Median age at transplant was 462 days (0 days to 2.5 years). The median time to pacemaker placement was 190 days (18-1,672 days) after transplantation. Indications were sick sinus syndrome (SSS) in 5 and heart block in 2 patients (1 during acute rejection). Three patients with SSS underwent electrophysiology studies (EPS); 1 was normal and 2 showed sinus node dysfunction. The mode of pacing was VVIR in 6 patients and VVI in 1 patient. All 6 survivors are doing well and 5 patients' pacemakers still provide support. These 7 patients were compared with 185 pediatric patients (0 days to 12-years-old) transplanted during 1985 through 1993 who survived at least 6 months after transplantation. There was no correlation between the receipt of a pacemaker and graft cold ischemic time, rejection history, donor age, or recipient age at transplantation. The 5 patients with SSS had significantly lower average heart rates in the first month after transplantation (108 +/- 16 vs 130 +/- 12; P = 0.0002). The need for permanent pacemakers in this population is uncommon. Pacemakers, however, can be safely performed when necessary with excellent clinical results.

(1) An optimum AV delay is an important component of hemodynamic performance; and (2) AV sequential pacing at rest with an optimum AV delay may provide better hemodynamic performance than atrial pacing with intrinsic ventricular conduction when native AV conduction is prolonged > 220 msec.

While dual chamber pacing is considered superior to VVI pacing at rest, there is a continuing debate as to the relative benefit of AV synchrony versus rate increase with exercise. To evaluate this question and to correlate different methods of evaluation, 14 patients with DDDR pacemakers were studied using serial treadmill exercise test with a CAEP protocol. Patients were exercised in DDD, DDDR, and VVIR modes. Echo-Doppler cardiac outputs were determined and pulmonary gas exchange was measured during exercise. There was a significant improvement in cardiac output with exercise in the DDDR versus VVIR modes, and in DDDR versus DDD modes in patients with chronotropic incompetence. There were small increases in exercise duration in DDDR versus VVIR modes, and small but consistent increases in VO2 at all levels of exercise, though not statistically significant. In this group of patients, DDDR pacing was superior to VVIR pacing, and superior to DDD pacing when chronotropic incompetence was present.

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