Dual-Site Ventricular Pacing in Fontan Patients With Heart Block

Oct 18, 2018
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Authors:
O’Leary ET, Gauvreau K, Alexander ME, et al.
Citation:
Dual-Site Ventricular Pacing in Patients With Fontan Physiology and Heart Block: Does it Mitigate the Detrimental Effects of Single-Site Ventricular Pacing? JACC Clin Electrophysiol 2018;4:1289-1297.
Summary By:
Martin LaPage, MD, FACC

Study Questions:

Does dual-site (cardiac resynchronization therapy [CRT]) ventricular pacing in Fontan patients mitigate the detrimental effects of single-site ventricular pacing (SSVP)?

Methods:

This is a single-center retrospective review of Fontan patients undergoing pacemaker implant for high-grade atrioventricular (AV) block between 1990 and 2016. The primary endpoint was death or heart transplantation.

Results:

Of 105 eligible patients, 42 were excluded due to <12 months of follow-up. Included were 43 with SSVP and 19 with CRT having undergone implant at a median of 4-5 years of age. The primary outcome occurred in 5% of the CRT and 25% of the SSVP patients (p = 0.09). Kaplan-Meier freedom from outcome was similar over a 5-year period. The CRT cohort had less change in ventricular function over time, but 5-year Kaplan-Meier analysis showed no difference in ventricular function between groups.

Conclusions:

There was no significant difference in long-term outcomes between CRT and SSVP for Fontan patients paced for high-grade AV block.

Perspective:

The conclusions from this study may be in the eye of the beholder. This retrospective study is limited significantly by a treatment selection bias – one could assume that sicker patients at baseline would be more likely to get a CRT device, and this is confirmed by the significant difference in baseline ventricular function between groups. Perhaps the CRT group with significantly greater incidence of depressed function would have fared much worse with SSVP as the SSVP group’s ventricular function declined over time versus no change in the CRT group.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Interventions, Acute Heart Failure, Heart Transplant

Keywords: Arrhythmias, Cardiac, Atrioventricular Block, Cardiac Resynchronization Therapy, Fontan Procedure, Heart Block, Heart Failure, Heart Transplantation, Pacemaker, Artificial, Ventricular Function


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