title: Long-term follow-up shows excellent transmural atrial lead performance in patients with complex congenital heart disease.
abstract: 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.
  
  
  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 were reviewed for patient data and acute and long-term lead performance for TMA leads placed 1998 to 2004. Forty-two of 48 TMA leads remain active at last follow-up. Two leads fractured, 4 were functional at >5-year follow-up but no longer active. Freedom from lead failure 98% (95% confidence interval, 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 3 and 2.8 mV, respectively; median acute and chronic pacing thresholds at 0.5 ms were 0.9 and 0.7 V, respectively. TMA leads performed similarly in Fontan patients. Overdrive pacing for intra-atrial re-entrant tachycardia was successful in 7 of 8 patients. One patient with high baseline risk died of stroke 7 years after 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 re-entrant tachycardia could benefit most from routine use of this technique.
authors.affiliation: From the Department of Pediatrics, Division of Cardiology (M.R.W., S.M.S., N.K.B., J.C.P.), and Department of Surgery, Division of Pediatric Cardiac Surgery (J.J.L.), University of California, San Diego and Rady Children's Hospital, San Diego, CA. m8williams@ucsd.edu.
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Williams
authors.affiliation: From the Department of Pediatrics, Division of Cardiology (M.R.W., S.M.S., N.K.B., J.C.P.), and Department of Surgery, Division of Pediatric Cardiac Surgery (J.J.L.), University of California, San Diego and Rady Children's Hospital, San Diego, CA.
authors.forename: Suzanne M
authors.initials: SM
authors.lastname: Shepard
authors.affiliation: From the Department of Pediatrics, Division of Cardiology (M.R.W., S.M.S., N.K.B., J.C.P.), and Department of Surgery, Division of Pediatric Cardiac Surgery (J.J.L.), University of California, San Diego and Rady Children's Hospital, San Diego, CA.
authors.forename: Nicole K
authors.initials: NK
authors.lastname: Boramanand
authors.affiliation: From the Department of Pediatrics, Division of Cardiology (M.R.W., S.M.S., N.K.B., J.C.P.), and Department of Surgery, Division of Pediatric Cardiac Surgery (J.J.L.), University of California, San Diego and Rady Children's Hospital, San Diego, CA.
authors.forename: John J
authors.initials: JJ
authors.lastname: Lamberti
authors.affiliation: From the Department of Pediatrics, Division of Cardiology (M.R.W., S.M.S., N.K.B., J.C.P.), and Department of Surgery, Division of Pediatric Cardiac Surgery (J.J.L.), University of California, San Diego and Rady Children's Hospital, San Diego, CA.
authors.forename: James C
authors.initials: JC
authors.lastname: Perry
mesh_terms: D000293:Adolescent; D000328:Adult; D001145:Arrhythmias, Cardiac / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D016275:Atrial Function; D002304:Cardiac Pacing, Artificial / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000401:mortality; D002648:Child; D002675:Child, Preschool; D018572:Disease-Free Survival; D004867:Equipment Design; D004868:Equipment Failure; D018729:Fontan Procedure / Q000009:adverse effects; D006325:Heart Atria / Q000503:physiopathology; D006330:Heart Defects, Congenital / Q000401:mortality / Q000601:surgery*; D006801:Humans; D007223:Infant; D053208:Kaplan-Meier Estimate; D010138:Pacemaker, Artificial; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
keywords: Fontan procedure; cardiac pacing, artificial; heart defects, congenital