1. The Placement of Atrial Pacing Leads in Patients after Cardiac Surgery
Dept. of Cardiology, First Affiliated Hospital, Nanjing Medical University
Jiangang Zou, M.D.; Ph.D.

2. Introduction
The incidence of AVB and SND following open-heart surgery for congenital heart disease: 1%~4%
The incidence of bradyarrhythmias after cardiac transplantation varies from 8% to 23%
The experience of the permanent pacing after open-heart surgery is rare
The placement of atrial pacing leads

3. Circulation 2008,117:e350-e408

4. Recommendations for permanent pacing in children, adolescents, and patients with congenital heart disease

5. Recommendations for permanent pacing in children, adolescents, and patients with congenital heart disease

6. Recommendation for pacing after cardiac transplantation

7. The implantation of pacing leads
Transvenous:
Cephelic/subclavian puncture/active lead
Epicardial:
small body size
Fontan-type procedures
tricuspid valve replacement
The placement of atrial pacing leads

8. Europace 2007,9:426-31

11. Lead failures:
EPI: 18% OF ATRIAL LEADS, 24% OF VENTRICULAR LEADS
ENDO: 5% OF VENTRICULAR LEADS
Single-lead, VVIR ENDO pacing had higher efficiency and safety than EPI.

12. Ann Thorac Surg. 2008;85(5):

13. 239 bipolar steroid-eluting epicardial leads in 114 cases
12-year follow-up
Average atrial and ventricular threshold:1.2V/0.5ms
Thresholds of LA and RA: 0.82V/0.5ms and 0.74V/0.5ms
Thresholds of LV and RV: 0.96V/0.5ms and 0.94V/0.5ms
P sensing of LA and RA: 3.4mV and 2.9mV
V sensing of LV and RV: 11.2mV and 7.7mV
Lead failure: 19(8%)
Lead survival at 2 and 5 year :
99% and 94% for atrial leads
96% and 85% for ventricular leads

14. Bipolar steroid-eluting epicardial leads demonstrate excellent sensing characteristics and persistent low pacing threshold

15. Eur J Cardiothorac Surg 2000;17:455-461

21. Transvenous pacing in the pediatric population is associated with a lower threshold and lower rate of lead-related complications
If EPI lead necessary, steroid-eluting leads recommended

22. J Thorac Cardiovasc Surg 1999;117:523-528

24. Lead failure: 4 (epi) vs 4 (endo)
Lead survival at 2 year: 91% (epi) vs 87% (endo)

25. Steroid-eluting epi leads have the same longevity as the conventional endo lead
Pacing and sensing are similar
Steroid-eluting epi leads are good alternatives for endo leads for small children

26. PACE 2009:32:

29. Compared to epi lead, transvenous atrial pacing lead may be placed in Fontan patients with lower procedure morbidity and expectation of lead performance and longevity.

30. 3 DDD cases after surgery atrial lead characteristics:
sensing threshold impedance lead
pt.1 at impant(17y) mv V/0.4ms passive
follow-up(4y) mv no capture
pt.2 at impant(34y) mv V/0.4ms active
follow-up(41y) mv V/0.4ms
pt.3 at impant(14y) mv V/0.4ms active
follow-up(3y) mv V/0.4ms

31. conclusions The placement of atrial lead: endocardial and epicardial
Endocardial: screw-in, older children
Epicardial:
steroid-eluting lead recommended
small body size
Fontan-type procedures
tricuspid valve replacement
Follow-up

32. Thanks for your attention!