Permanent Cardiac Pacing in Children: Choosing the Optimal Pacing Site

Abstract

Background-We evaluated the effects of the site of ventricular pacing on left ventricular (LV) synchrony and function in children requiring permanent pacing. Methods and Results-One hundred seventy-eight children (aged <18 years) from 21 centers with atrioventricular block and a structurally normal heart undergoing permanent pacing were studied cross-sectionally. Median age at evaluation was 11.2 (interquartile range, 6.3-15.0) years. Median pacing duration was 5.4 (interquartile range, 3.1-8.8) years. Pacing sites were the free wall of the right ventricular (RV) outflow tract (n=8), lateral RV (n=44), RV apex (n=61), RV septum (n=29), LV apex (n=12), LV midlateral wall (n=17), and LV base (n=7). LV synchrony, pump function, and contraction efficiency were significantly affected by pacing site and were superior in children paced at the LV apex/LV midlateral wall. LV dyssynchrony correlated inversely with LV ejection fraction (R=0.80, P=0.031). Pacing from the RV outflow tract/lateral RV predicted significantly decreased LV function (LV ejection fraction <45%; odds ratio, 10.72; confidence interval, 2.07-55.60; P=0.005), whereas LV apex/LV midlateral wall pacing was associated with preserved LV function (LV ejection fraction ≥55%; odds ratio, 8.26; confidence interval, 1.46-47.62; P=0.018). Presence of maternal autoantibodies, gender, age at implantation, duration of pacing, DDD mode, and QRS duration had no significant impact on LV ejection fraction. Conclusions-The site of ventricular pacing has a major impact on LV mechanical synchrony, efficiency, and pump function in children who require lifelong pacing. Of the sites studied, LV apex/LV midlateral wall pacing has the greatest potential to prevent pacing-induced reduction of cardiac pump function. (Circulation. 2013;127:613-623.)

Speckle-Tracking Echocardiography Elucidates the Effect of Pacing Site on Left Ventricular Synchronization in the Normal and Infarcted Rat Myocardium

“…While many studies support the notion that LV-only pacing may have beneficial effects in HF patients [26], recent data in children with normal cardiac function and complete AV block demonstrated striking similarity to the results of our rat model in regard to LVonly pacing [27]. Moreover, LV-only pacing appears to be associated with good clinical outcome in this and other studies in the pediatric population [28,29]. It should be mentioned that the segmental findings of our study as well as the pediatric studies stated above appear to contrast the findings of [30], which demonstrated reduced Ecc near the LV pacing site compare to remote sites near the RV in the dog model of acute pacing.…”

High Incidence of Dilated Cardiomyopathy After Right Ventricular Inlet Pacing in Patients With Congenital Complete Atrioventricular Block

“…11, 14 They reported that LVEF was significantly inversely correlated with SPWMD (R 2 =0.454, P<0.001). 11 In the present study, the clinical parameters were the same among patients with RVI, RVA, and LV pacing within 1 year of PMI. These results may be explained by the retrospective study design, which included data from 30 years ago.…”

“…16, 17 We used the criteria of Manolio et al 18 for DCM diagnosis and defined DCM as having 117% of the normal LV right bundle branch block morphology was designated as the LV lateral wall or LV base. 11 The pacing sites were classified into 6 segments of RV and 17 segments of LV. To delineate the RV segments, a line was drawn from the membranous septum to the apex to divide the septum into anterior and inferior halves; further subdividing the base to apex length into 3 parts (basal, middle, and apical) provided 6 segments.…”

Twenty-Seven Years Experience With Transvenous Pacemaker Implantation in Children Weighing <10 kg

“…35 Together with the higher venous occlusion rate in the smallest of infants, our approach has been modified such that, transvenous pacing is no longer first line for patients <5 kg. We now favor placement of steroid-eluting epicardial leads on the left ventricle reserving transvenous pacing with a 4.1F lead for failure of the epicardial system or complications.…”