Temporary-Endoepicardial Atrioventricular Sequential Pacing for Complete Heart Block Following Complex Surgery for Congenital Heart Disease

Ulhas M Pandurangi, PJ Ruth, Satish C Toal,
Snehal Kulkarni, KS Murthy, KM Cherian

Department of Cardiology, Madras Medical Mission,
Institute of Cardiovascular Diseases, Chennai

Complete heart block following intracardiac surgical repair for complex congenital heart disease is not uncommon. In the presence of ventricular dysfunction, ventricular pacing alone may not improve the cardiac output. We report the feasibility and efficacy of endoepicardial atrioventricular sequential pacing in a case of postoperative complete heart block. (Indian Heart J 2003; 55: 68–70)

Key Words: Complete heart block, Atrioventricular sequential pacing, Cardiac surgery

Intracardiac surgical repair for complex congenital heart disease is associated with complete heart block (CHB) in up to 36% of cases.1 In the presence of ventricular dysfunction, atrioventricular (AV) sequential pacing is preferred to ventricular pacing alone.2,3 We report the case of a 12-year-old girl who developed CHB following mitral valve replacement for residual mitral regurgitation and moderate biventricular dysfunction. She had undergone an intracardiac repair in the past for complex congenital heart disease. The epicardial ventricular pacing lead provided VVI pacing. However, the poor hemodynamics resulted in the patient being dependent on the ventilator. A transvenous endocardial pacing lead was placed in the right atrium through the jugular vein and AV sequential pacing achieved using an epicardial ventricular pacing lead, with gratifying results. This report highlights the feasibility of endoepicardial AV sequential pacing and the need for AV synchrony in cases of postoperative CHB.

Case Report

A 12-year-old girl had undergone surgical closure for atrial and ventricular septal defects, with subpulmonic resection at 6 years of age for situs inversus, dextrocardia, atrial and ventricular septal defects, corrected transposition of the great arteries (c-TGA), subpulmonic stenosis and interrupted inferior vena cava. The patient underwent a redo surgery for new-onset progressive mitral valve regurgitation. An Omnicarbon prosthetic valve (29 mm) was placed at the mitral annulus. A bipolar epicardial ventricular pacing lead was placed as there was CHB following the surgery (Fig. 1). The patient was paced in the VVI mode (Fig. 2) using a temporary pacemaker (Medtronic 5346 DDD temporary pulse generator, Minneapolis, MN, USA). The patient came out of bypass easily. However, despite good surgical results, the patient could not be weaned away from the ventilator even 48 hours postprocedure, as there were signs of reduced cardiac output and systemic venous congestion. Despite inotropic support, the systolic blood pressure remained less than 90 mmHg and central venous pressure between 16 and 18 mmHg. The arterial blood gas analyses were suggestive of metabolic acidosis. The loss of atrial kick was considered a contributory factor for the reduced cardiac output and AV sequential pacing was considered to improve the hemodynamics.4 A temporary bipolar 5 F pacing lead was placed in the left-sided right atrium through the left internal jugular vein. The tip of this lead was positioned under the fluoroscope to achieve stable and satisfactory pacing and sensing parameters (Fig. 3). This endocardial lead and the epicardial lead were connected to the AV sequential pacemaker (Medtronic 5388 Inc., Minneapolis, MN, USA). The AV delay was adjusted to 100 ms with the aid of venous pressure monitoring5 and bedside Doppler study6 of the mitral inflow and mitral regurgitation (Figs 4 and 5). There was marked improvement in the hemodynamics soon after AV sequential pacing was initiated. The systolic blood pressure could be maintained between 120 and 130 mmHg without inotropic support, and there was prompt normalization of the central venous pressure and arterial blood gas parameters. The patient could be successfully weaned away from the ventilator over 24 hours and underwent dual-chamber permanent pacemaker implantation before discharge from the hospital.

Discussion

Complete heart block following cardiac surgery for complex congenital heart disease, like the one our patient had, is not uncommon. Surgical repair for defects associated with c-TGA results in CHB in up to 36% of cases.1,7 Postoperative CHB may be managed satisfactorily in most cases by ventricular pacing in the VVI mode alone through epicardial leads.8,9 However, in certain situations in which the atrial contribution to ventricular output is critical, as in our case where there was moderate biventricular dysfunction, it has been shown that AV sequential pacing results in better hemodynamics as compared to ventricular pacing alone. It has been common practice in some surgical centers to place atrial and ventricular epicardial pacing leads for post-surgical CHB to achieve AV sequential pacing.10,11 However, if only one epicardial lead is available for ventricular pacing, AV sequential pacing can be obtained by an esophageal lead, which can sense atrial potentials.12 The disadvantages of using esophageal leads are unstable lead position and intermittent sensing failure. In addition, an esophageal lead is not practical in a conscious patient. Placement of another epicardial lead for sequential pacing would add to the perioperative morbidity. Using epicardial leads for ventricular pacing and a Swan–Ganz flow-directed pacing catheter for atrial pacing/sensing to obtain AV sequential pacing has met with variable results.13 Endocardial atrial lead placement is another option for obtaining AV sequential pacing. Since our patient had interruption of the inferior vena cava, the jugular vein was used for right atrial access. The left jugular vein was chosen as the patient had situs inversus. This case report highlights the occasional need for AV sequential pacing in a case of postoperative CHB and the feasibility of achieving sequential pacing by endoepicardial leads.

Correspondence:

Dr Ulhas M Pandurangi,
Department of Cardiology,
Institute of Cardiovascular Diseases,
Madras Medical Mission, 4-A,

Dr J Jayalalitha Nagar,
Mogappair, Chennai 600050.
e-mail: ulhaspandurangi@hotmail.com


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