Pacemaker in children – big shoes to fill for small foot

Joseph Theodore*, Maniram Krishna, Gautam, Murshid

Department of Cardiology, Kauvery Hospital-Heart city, Trichy, India

*Correspondence: Email: josephtheodore84@gmail.com; Tel:+91 81050 51480.

Abstract

A 3-year-old barely weighing 13 kg presented with failure of her epicardial pacing system and was implanted a transvenous single chamber successfully taking all due precautions.

Keywords: Pacemaker; Transvenous; Children

Background

To highlight the feasibility of implanting a transvenous pacemaker in small children.

Case Presentation

Pacemaker-in-children

A 3-year-old kid who developed third degree heart block after Tetralogy of Fallot (TOF) intracardiac repair was implanted epicardial pacemaker two years ago. She developed exercise intolerance and her pacemaker interrogation revealed epicardial lead failure leading to loss of capture. As the kid was only weighing only 13 kg, it was a challenge to use a regular transvenous pacemaker. But after obtaining consent from parents a transvenous pacemaker (VVIR Sensia, Medtronic) was implanted making an alpha loop (FIG) to allow for redundancy of 52 cm active fixation lead at mid interventricular septum. Pacing parameters were optimal and stability of leads were confirmed. And also, since the chest wall was thin, pulse generator was placed in subpectoral pocket and pulse generator of the epicardial pacemaker was removed.

Discussion

Transvenous pacemaker in infants and young children has always been a therapeutic dilemma for treating physician. This is mostly caused by different sets of institutional practice depending on the clinical indication. As pacemakers are not custom manufactured for children, sheer size of these devices precludes their use in small children. General indication for pacemaker when heart rate is less than 50 in neonates (40 in toddlers) and also when heart block due to corrective congenital heart surgery is likely to persist for more than one week. In our institute, before transvenous pacing in children heart rate cut off alone is not taken as an indication but chronotropic incompetence, failure to thrive plays a major factor in decision making. This is primarily because of redundant lead length and the device size which needs subpectoral pocket because of thin chest in kids. Globally single chamber endocardial transvenous pacemaker is done when the child weighs more than 10 kg and dual chamber when atleast 20 kg are achieved (subject to institutional guidelines) and epicardial pacemakers are preferred when these criteria are not met or concomitant cardiac surgery is planned [1].

Common problem of epicardial pacing is lead failure and high threshold leading battery depletion which necessitates transvenous pacing as in our case.

New modalities of pacing like leadless pacing and conduction system pacing also have showed promising short-term results in children [2].

Conclusion

This case report highlights the feasibility of transvenous pacemaker even in children weighing less than 15 kg if due precautions are taken to accommodate for the larger device and excessive lead length.

Acknowledgement

We acknowledge Dr. Shanthi, Medical Administrator, Kauvery-HeartCity, Mr. Androse Nithyadoss, GM, Kauvery HeartCity for providing the financial support to perform the case free of cost to the patient.

Author Contribution

All authors involved in concept, management and reviewing the patient’s case and drafted the report.

Competing interests

The authors have no competing interest to declare.

References

  1. Fortescue EB, Berul CI, Cecchin F, Walsh EP, Triedman JK, Alexander ME. Patient, procedural, and hardware factors associated with pacemaker lead failures in pediatrics and congenital heart disease. Heart Rhythm. 2004;1:150–159.
  2. Roberts PR, Clementy N, Al Samadi F, et al. A leadless pacemaker in the realworld setting: the micra transcatheter pacing system post-approval registry. Heart Rhythm. 2017;14:1375–1379.

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