Long-Term Follow-Up Shows Excellent Transmural Atrial Lead Performance in Patients with Complex Congenital Heart Disease
Background—Many patients with congenital heart disease require permanent pacing for rhythm management but cannot undergo transvenous lead placement. In others, epicardial scarring prohibits adequate sensing and pacing thresholds using epicardial leads. This study describes long-term lead performance using a transmural atrial (epicardial-to-endocardial) pacing approach in patients with congenital heart disease.
Methods and Results—For transmural atrial (TMA) lead access, a bipolar, steroid-eluting transvenous lead was placed from the epicardium via purse-string incision or atriotomy and affixed to atrial endocardium. Records reviewed for patient data and acute and long-term lead performance for TMA leads placed 1998-2004. Forty-two of 48 TMA leads remain active at last follow-up. Two leads fractured, 4 were functional at >5 years follow-up but no longer active. Freedom from lead failure 98% (95% CI 86-100%) at mean follow-up 7.8 years. TMA leads gave excellent sensing and pacing characteristics at implant and chronically. Median acute and chronic sensing thresholds were 3mV and 2.8mV, median acute and chronic pacing thresholds at 0.5ms were 0.9V and 0.7V, respectively. TMA leads performed similarly in Fontan patients. Overdrive pacing for intra-atrial reentrant tachycardia successful in 7/8 patients. One patient with high baseline risk died of stroke seven years post-implant. No lead-associated thrombi were observed.
Conclusions—TMA pacing leads had excellent longevity, initial, and chronic functional properties and provide an alternative to epicardial leads in patients with congenital heart disease. Patients who cannot receive transvenous leads, have epicardial scarring, or have intra-atrial reentrant tachycardia could benefit most from routine use of this technique.
- Received August 14, 2013.
- Revision received April 30, 2014.
- Accepted May 4, 2014.