Longitudinal Outcomes of Epicardial and Endocardial Pacemaker Leads in the Adult Fontan Patient
Placement of an epicardial pacemaker system is often preferred over an endocardial system in patients who have undergone a Fontan operation, but data are limited on how these two systems perform over time in patients with Fontan palliation. We performed a retrospective review of adults with Fontan palliation who had pacemaker implantation and interrogation data at Mayo Clinic from 1994 to 2014. Lead parameters, pacing mode, and polarity were collected at the earliest device interrogation report. Clinic notes and device interrogation reports were reviewed at implantation, 6 months, and yearly after implantation to determine impedance, capture threshold (CT), and energy threshold (ET). There were 87 patients with 168 leads in the study cohort. The mean follow-up time was 7.7 years (6 months–19 years). There were 143 epicardial leads (57 atrial and 86 ventricular) and 25 endocardial leads (20 atrial and 5 ventricular). There was no difference in the baseline lead parameters between epicardial and endocardial leads for impedance (610 ± 259 versus 583 ± 156 Ω, p = 0.93), CT (2.0 ± 1.3 versus 1.8 ± 1.3 V, p = 0.28), or ET (7.1 ± 12.5 versus 6.8 ± 18.1 µJ, p = 0.29). Compared to endocardial leads, ventricular epicardial leads were associated with temporal decrease in impedance and increase in ET. Regarding clinical outcomes, epicardial leads had higher rates of failure but similar generator longevity in comparison to endocardial leads. Ventricular epicardial leads were associated with temporal decrease in impedance and increase in ET. Epicardial leads had a higher rate of failure but similar generator longevity compared to endocardial leads.
KeywordsFontan palliation Adult congenital heart disease Pacemaker Epicardial leads Transvenous leads Capture threshold
GDH contributed to concept/design, data analysis/interpretation, drafting article, and statistics. AJD contributed to concept/design and critical revision of article. CAW contributed to concept/design and approval of article. SK contributed to concept/design and critical revision of article. ACE contributed to concept/design, data interpretation, drafting article, and critical revision of article.
Compliance with Ethical Standards
Conflict of interest
The authors have no conflicts of interest.
- 1.Nakano T, Kado H, Tatewaki H, Hinokiyama K, Oda S, Ushinohama H, Sagawa K, Nakamura M, Fusazaki N, Ishikawa S (2015) Results of extracardiac conduit total cavopulmonary connection in 500 patients. Eur J Cardiothorac Surg 48(6):825–832. https://doi.org/10.1093/ejcts/ezv072 (discussion 832)CrossRefPubMedGoogle Scholar
- 2.Iyengar AJ, Winlaw DS, Galati JC, Wheaton GR, Gentles TL, Grigg LE, Justo RN, Radford DJ, Weintraub RG, Bullock A, Celermajer DS, d’Udekem Y (2014) The extracardiac conduit Fontan procedure in Australia and New Zealand: hypoplastic left heart syndrome predicts worse early and late outcomes. Eur J Cardiothorac Surg 46(3):465–473. https://doi.org/10.1093/ejcts/ezu015 (discussion 473)CrossRefPubMedGoogle Scholar
- 3.Ono M, Kasnar-Samprec J, Hager A, Cleuziou J, Burri M, Langenbach C, Callegari A, Strbad M, Vogt M, Horer J, Schreiber C, Lange R (2016) Clinical outcome following total cavopulmonary connection: a 20-year single-centre experience. Eur J Cardiothorac Surg 50(4):632–641. https://doi.org/10.1093/ejcts/ezw091 CrossRefPubMedGoogle Scholar
- 4.Pundi KN, Johnson JN, Dearani JA, Li Z, Hinck CA, Dahl SH, Cannon BC, O’Leary PW, Driscoll DJ, Cetta F (2015) 40-year follow-up after the Fontan operation: long-term outcomes of 1,052 patients. J Am Coll Cardiol 66(15):1700–1710. https://doi.org/10.1016/j.jacc.2015.07.065 CrossRefPubMedGoogle Scholar
- 6.Tweddell JS, Nersesian M, Mussatto KA, Nugent M, Simpson P, Mitchell ME, Ghanayem NS, Pelech AN, Marla R, Hoffman GM (2009) Fontan palliation in the modern era: factors impacting mortality and morbidity. Ann Thorac Surg 88(4):1291–1299. https://doi.org/10.1016/j.athoracsur.2009.05.076 CrossRefPubMedGoogle Scholar
- 7.Egbe AC, Connolly HM, Dearani JA, Bonnichsen CR, Niaz T, Allison TG, Johnson JN, Poterucha JT, Said SM, Ammash NM (2016) When is the right time for Fontan conversion? The role of cardiopulmonary exercise test. Int J Cardiol 220:564–568. https://doi.org/10.1016/j.ijcard.2016.06.209 CrossRefPubMedGoogle Scholar
- 9.Williams MR, Shepard SM, Boramanand NK, Lamberti JJ, Perry JC (2014) Long-term follow-up shows excellent transmural atrial lead performance in patients with complex congenital heart disease. Circ Arrhythm Electrophysiol 7(4):652–657. https://doi.org/10.1161/CIRCEP.113.001321 CrossRefPubMedGoogle Scholar
- 12.Lau KC, William Gaynor J, Fuller SM, Karen AS, Shah MJ (2015) Long-term atrial and ventricular epicardial pacemaker lead survival after cardiac operations in pediatric patients with congenital heart disease. Heart Rhythm 12(3):566–573. https://doi.org/10.1016/j.hrthm.2014.12.001 CrossRefPubMedGoogle Scholar
- 13.McLeod CJ, Attenhofer Jost CH, Warnes CA, Hodge D 2nd, Hyberger L, Connolly HM, Asirvatham SJ, Dearani JA, Hayes DL, Ammash NM (2010) Epicardial versus endocardial permanent pacing in adults with congenital heart disease. J Interv Card Electrophysiol 28(3):235–243. https://doi.org/10.1007/s10840-010-9494-4 CrossRefPubMedGoogle Scholar
- 17.Takahashi K, Cecchin F, Fortescue E, Berul CI, Alexander ME, Walsh EP, Fynn-Thompson F, Triedman JK (2009) Permanent atrial pacing lead implant route after Fontan operation. Pacing Clin Electrophysiol 32(6):779–785. https://doi.org/10.1111/j.1540-8159.2009.02365.x CrossRefPubMedPubMedCentralGoogle Scholar
- 18.Cohen MI, Vetter VL, Wernovsky G, Bush DM, Gaynor JW, Iyer VR, Spray TL, Tanel RE, Rhodes LA (2001) Epicardial pacemaker implantation and follow-up in patients with a single ventricle after the Fontan operation. J Thorac Cardiovasc Surg 121(4):804–811. https://doi.org/10.1067/mtc.2001.113027 CrossRefPubMedGoogle Scholar
- 19.Shah MJ, Nehgme R, Carboni M, Murphy JD (2004) Endocardial atrial pacing lead implantation and midterm follow-up in young patients with sinus node dysfunction after the Fontan procedure. Pacing Clin Electrophysiol 27(7):949–954. https://doi.org/10.1111/j.1540-8159.2004.00564.x CrossRefPubMedGoogle Scholar
- 25.Fortescue EB, Berul CI, Cecchin F, Walsh EP, Triedman JK, Alexander ME (2004) Patient, procedural, and hardware factors associated with pacemaker lead failures in pediatrics and congenital heart disease. Heart Rhythm 1(2):150–159. https://doi.org/10.1016/j.hrthm.2004.02.020 CrossRefPubMedGoogle Scholar