Permanent pacing in children with isolated congenital complete atrioventricular block may cause left ventricular dysfunction. To prevent it, alternative pacing sites have been proposed: left ventricular epicardial or selective right ventricular endocardial pacing.

To compare the functional outcome (left ventricular systolic function and synchrony) in paediatric patients with congenital complete atrioventricular block and left ventricular apical epicardial or right ventricular transvenous mid-septal pacing.

Retrospective study. Epicardial leads were implanted by standard surgical technique, transvenous leads by 3D electroanatomic mapping systems. 3D mapping acquired 3D right ventricular local pacing map and defined the narrowest paced QRS site. 3D mapping guided screw-in bipolar leads on that ventricular site. Electrocardiogram (ECG) (QRS duration) and echocardiographic data (synchrony: interventricular mechanical delay, septal to posterior wall motion delay, systolic dyssynchrony index; contractility: global longitudinal strain, ejection fraction) were recorded. Data are reported as median [interquartile ranges]. p < 0.05 was significant.

There were 19 transvenous systems (age 8.8 [6–14] years; right ventricular mid-septum) and 17 epicardial systems (0.04 [0.001–0.6] years; left ventricular apex). Post-implantation QRS significantly widened either in endocardial or in epicardial patients. Most patients reached 4-year follow-up. One-year and 4-year ejection fraction and global longitudinal strain were mostly within normal limits and did not show significant differences between the two groups and between the same endocardial/epicardial group. Synchrony parameters were within normal limits in the two groups.

Left ventricular apical epicardial pacing and 3D mapping-guided right ventricular mid-septal pacing preserved left ventricular contractility and synchrony in children and adolescents with congenital complete atrioventricular block at short-/mid-term follow-up, without relevant significant differences between the two groups.

Temporary pacing wires have been associated with serious postoperative complications. Recommendations for their routine use after open heart surgery are decades old, and may not reflect current surgical techniques and outcomes.

The electronic web-enabled medical records of all patients undergoing congenital cardiac surgery from February, 2002, through December, 2005, were reviewed, excluding patients undergoing implantation of pacemakers as a primary procedure, or those undergoing ligation of a patent arterial duct.

There were 1193 surgical procedures performed, 1041 with cardiopulmonary bypass. Median age of the patients was 5.8 months, with a range from 0 days to 54 years, weighing 6.2 kilograms, with a range from 1 to 114 kilograms. Mortality prior to discharge was 2.5%, and median postoperative stay was 6 days. No deaths were attributed to arrhythmias. Temporary pacing wires were placed 14 times (1.2%). Indications for placement included sinus nodal dysfunction in 8 patients, preoperative in 4 and intraoperative in 4, high degree atrioventricular block in 4 patients, and intraoperative atrial flutter in 2 patients. Of these patients, 4 (0.3%) eventually underwent permanent implantation of a pacemaker, 2 for persistent sinus nodal dysfunction, and 2 for persistent atrioventricular block. Postoperative junctional ectopic tachycardia requiring antiarrhythmic therapy occurred in 9 patients (0.8%). All recovered without incident, and none were treated with temporary pacing.

The diminished risk of unexpected postoperative arrhythmias in the current era alleviates the necessity for routine placement of temporary pacing wires. Those institutions with experienced surgical and cardiac critical care teams may be able to predict the need for temporary pacing wires preoperatively or intraoperatively.