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Impact of Atrial Pacing in Fontan Patients with Junctional Rhythm: A Prospective Echocardiographic Study

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Abstract

Sinus node dysfunction (SND) with junctional rhythm (JR) is common after the Fontan operation. Atrial pacing (AP) restores atrioventricular (AV) synchrony, but the placement of a pacemaker carries significant morbidity. To study the impact of AP on echocardiographic parameters of function in Fontan patients with SND and JR. Nine Fontan patients with AP for SND and JR were prospectively studied with echocardiography in the following conditions—baseline paced rhythm, underlying JR and, if possible, slow-paced rhythm below their baseline paced rate (~ 10 bpm faster than their JR rate). Cardiac index was significantly lower in JR (3 ± 1.1 L/min/m2) vs AP (4.2 ± 1.4 L/min/m2; p = 0.002). Diastolic function also significantly worsened with increased ratio of early diastolic systemic AV valve inflow velocity to early diastolic systemic AV valve annulus velocity (E/e′ ratio) by tissue Doppler imaging (TDI) in JR (11.6 ± 4.6) vs AP (8.8 ± 2.2, p = 0.016). Pulmonary venous flow reversal was present in 7/9 patients in JR vs 0/9 in AP (p = 0.016). There were no significant differences in these echocardiographic measurements between the paced and slow-paced conditions. When compared to AP, JR was associated with a significant reduction in cardiac output and diastolic function, and an increased prevalence of pulmonary vein flow reversal. There were no differences between paced and slow-paced conditions, suggesting that AV synchrony rather than heart rate was primarily contributing to cardiac output. Further studies are needed to understand the chronic impact of JR on Fontan outcomes.

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Abbreviations

AP:

Atrial pacing, atrial paced and atrial pacemaker

AV:

Atrioventricular

Bpm:

Beats per minute

E/e′ ratio:

Ratio of early diastolic systemic atrioventricular valve inflow velocity to early diastolic systemic atrioventricular valve annulus velocity

IRB:

Institutional Review Board

JR:

Junctional rhythm

SND:

Sinus node dysfunction

TDI:

Tissue Doppler imaging

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Authors and Affiliations

  1. Division of Pediatric Cardiology, Oregon Health and Science University, 707 SW Gaines Street, Mail code: CDRC-P, Portland, OR, 97239, USA

    Emily L. Yang, Patrick D. Evers, Mia J. Long, Mina Mostafavifar & Seshadri Balaji

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  1. Emily L. Yang
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Correspondence to Emily L. Yang.

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None of the authors have a relationship with industry-relevant to this manuscript. Seshadri Balaji has a research grant from Medtronic to study sudden cardiac death in hypertrophic cardiomyopathy. Seshadri Balaji is a consultant for Milestone Pharmaceuticals and Alta Thera Pharmaceuticals. The other authors have no disclosures.

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Yang, E.L., Evers, P.D., Long, M.J. et al. Impact of Atrial Pacing in Fontan Patients with Junctional Rhythm: A Prospective Echocardiographic Study. Pediatr Cardiol 45, 361–367 (2024). https://doi.org/10.1007/s00246-023-03345-0

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