Elsevier

Heart Rhythm

Volume 18, Issue 3, March 2021, Pages 434-442
Heart Rhythm

Pediatric and Congenital EP
Three-dimensional guided selective right ventricular septal pacing preserves ventricular systolic function and synchrony in pediatric patients

https://doi.org/10.1016/j.hrthm.2020.12.004Get rights and content

Background

Nonfluoroscopic 3-dimensional (3D) electroanatomic mapping systems (EAMs) have been developed to guide cardiac catheter navigation and reduce fluoroscopy. Selective right ventricular (RV) septal pacing could prevent pacing-induced left ventricular (LV) dysfunction.

Objective

The purpose of this study was to determine whether EAM-guided selective RV septal pacing preserves LV contractility/synchrony in pediatric patients with complete atrioventricular block (CAVB) and no other congenital heart defects.

Methods

Prospective analysis of children/adolescents who underwent EAM-guided selective RV pacing was performed. A 3D pacing map guided ventricular lead implantation at septal sites with narrow paced QRS. Serial echocardiograms were obtained after pacemaker implantation to monitor for function (volumes, ejection fraction [EF], global longitudinal/circumferential strain) and synchrony (interventricular mechanical delay, septal to posterior wall motion delay, systolic dyssynchrony index). Data are reported as median (25th–75th percentile).

Results

Thirty-two CAVB patients (age 9.8 [7.0–14.0] years; 11 with a previous pacing system) underwent selective RV septal pacing (13 DDD, 19 VVIR pacemaker; midseptum 22, parahisian 7, RV outflow tract 3) with narrow paced QRS (110 [100–120] ms) and low radiation exposure. Follow-up over 24 (5–33) months showed preserved LV function and synchrony, without significant differences between pacing sites (midseptum–parahisian) and mode (VVIR-DDD). EF decreased after implantation in patients without previous pacing, although values were mainly within normal limits. Three parahisian patients underwent early lead repositioning.

Conclusion

EAM-guided selective RV septal pacing is a feasible technique associated with preserved LV systolic function and synchrony and low radiation exposure in pediatric patients with CAVB.

Introduction

Alternative pacing sites have been proposed to prevent or reduce pacing-induced left ventricular (LV) dysfunction in children with complete atrioventricular block (CAVB).1, 2, 3 Nonfluoroscopic 3-dimensional (3D) electroanatomic mapping systems (EAMs) guide cardiac catheter navigation and reduce fluoroscopy during electrophysiological procedures. Some experiences with the use of EAM to guide pacing lead placement in adults4,5 and children6 have been reported. Our preliminary study showed that in a limited cohort of pediatric patients, EAM-guided selective right ventricular (RV) septal pacing (SRVSP) could preserve LV function and synchrony and could determine better global longitudinal strain (GLS) than RV apical pacing at short-term follow-up.7 The aim of this study was to measure LV systolic function and synchrony in a larger cohort of children following RV septal pacing.

Section snippets

Methods

This single-center, prospective study was conducted on children and adolescents requiring permanent pacing for CAVB and systemic LV in the absence of other congenital heart defects. Patients underwent pacemaker implantation between December 2014 and February 2020 at the Cardiac Arrhythmias Unit of Bambino Gesù Children’s Hospital. Demographic data, implantation procedure data, electrocardiographic (ECG) and echocardiographic findings, complications, and clinical status at follow-up were

Results

The study included 32 pediatric patients (23 female [72%]; age 9.8 [7.0–14.0] years at the time of the procedure). Data on the first 10 patients for the first year of follow-up have already been published in our previous study.7

Eleven patients (age 10.5 [8.0–17.0] years; 7 female) were already chronically paced (9 [8–13] years): 6 from RV site, and 5 from LV sites. They all underwent new pacing system implantation because of malfunctioning ventricular leads. Baseline ECG and echocardiographic

Discussion

The present study shows the outcome of a method to implant transvenous pacing leads in SRVSP. It describes the results of EAM-guided SRVSP in children and adolescents. A 3D pacing map identified the RV septal sites with the narrowest paced QRS, and EAM guided lead implantation into or close to these sites. Data show that SRVSP preserves LV function and synchrony in children and adolescents with CAVB at short- and mid-term follow-up.

The desired PHP site was reached in one-third of patients. MS

Conclusion

In children and adolescents requiring permanent ventricular pacing for CAVB, nonfluoroscopic 3D EAM guided transvenous lead implantation at selective RV septal sites. SRVSP was associated with preserved LV systolic function and synchrony at short- and mid-term follow-up. This EAM-guided SRVSP approach allowed low radiation exposures. Further studies and longer follow-up are needed for better evaluation of this approach.

Acknowledgments

The authors thank Dr Elisa Del Vecchio for valuable collaboration in the editorial revision; Drs Luigina Porco, Ilaria Cazzoli, and Camilla Calvieri (manuscript writing); and Engineers Greta Allegretti, Roberta Annibali, and Michele Ciani, Abbott St. Jude Medical, Italy (technical assistance).

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  • Cited by (4)

    Funding sources; The authors have no funding sources to disclose. Disclosures: The authors have no conflicts of interest to disclose.

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