Transpulmonary Atrial Pacing: An Approach to Transvenous Pacemaker Implantation After Extracardiac Conduit Fontan Surgery

Abstract

Patients with prior extracardiac (EC) conduit Fontan surgery are considered ineligible for transvenous atrial pacemaker implantation due to lack of venous access to the atrial myocardium. A new technique for atrial lead placement in the setting of this surgical anatomy is proposed. A 30-year-old female with prior EC Fontan surgery, incessant supraventricular tachycardia, sinus node dysfunction, and multi-organ failure was admitted to our hospital. After placement of a transvenous lead in the left pulmonary artery (LPA) for temporary pacing with ensuing clinical improvement, the patient was taken back to the catheterization laboratory for definitive treatment. After ablation of the supraventricular tachycardia and 3D mapping of the common atrium, a puncture through the LPA and into the left-sided atrium was performed. A transvenous lead was then attached to the base of the left-sided appendage where excellent pacing and sensing characteristics were observed. Follow-up transesophageal echocardiography revealed stable lead placement and absence of pericardial effusion. The patient was discharged to home several days later on warfarin therapy. Transpulmonary access to the left-sided atrium for patients with prior EC Fontan surgery is a feasible strategy for transvenous atrial pacing. Lead placement in this location is associated with excellent pacing characteristics and involves a limited segment of lead within the pulmonary venous atrium. The approach is technically straightforward and avoids the need for surgical pacemaker placement.