Total Left-Sided Chamber DDD Pacemaker Approach in Children

The video details a surgical technique for permanent pacemaker implantation in a pediatric patient diagnosed with congenital complete heart block (CCHB) of maternal lupus origin. A left posterolateral thoracotomy with muscle sparing was performed for pericardial access. Bipolar epicardial leads were positioned in the left atrium and ventricle to optimize cardiac synchrony and mitigate desynchrony-related complications. The pacemaker generator was positioned in a submuscular layer in the left flank. This strategy aims to enhance longevity and accommodate pediatric growth, thereby minimizing mechanical risks. 

Key Aspects of the Presented Approach 

There are several key aspects of this surgical approach are important to highlight, including: 

1. Left chamber pacing—This technique focuses on biventricular stimulation, promoting enhanced electromechanical synchrony, which results in improved left ventricular function during the postoperative period. 
2. Thoracotomy access—The choice of a posterolateral thoracotomy avoids sternal adhesions and facilitates precise lead placement within the constrained pediatric anatomy. 
3. Flank pocket positioning—This submuscular location in the flank was strategically chosen to reduce erosion risks and allow for better accommodation of the child’s growth in contrast to subclavian approaches that may require more frequent revisions. 

Results and Discussion 

Postoperative management, which included confirmation of lead stability and device programming for physiological chronotropic responses, resulted in significant improvement in ventricular function and resolution of ventricular dilation during subsequent follow-ups. This technique addresses specific challenges associated with pediatric device implantation, including growth accommodation and lead stability. Generator positioning minimizes reoperations attributed to trauma or erosion. Furthermore, left-sided stimulation is critical for patients with preexisting ventricular dysfunction, substantially reducing lifetime complication rates. These collective attributes enhance safety profiles compared to sternotomy, particularly in younger pediatric patients. The importance of specialized training and procedural accessibility is underscored. 

Conclusion 

The left posterolateral thoracotomy approach provides a significant alternative in pediatric pacemaker surgery, combining anatomical and electrophysiological optimization principles essential for managing CCHB effectively in growing children. 

References

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3. Brugada J, et al. Pharmacological and non-pharmacological therapy for arrhythmias in the pediatric population: EHRA and AEPC joint consensus statement. Europace. 2013;15(9):1337-82.
4. Magalhães LP, et al. Diretriz de Arritmias Cardíacas em Crianças e Cardiopatias Congênitas SOBRAC/DCC-CP. Arq Bras Cardiol. 2016;107(3):1-58.
5. Silva SMJ, et al. 2021 PACES Expert Consensus Statement on Indications and Management of Cardiovascular Implantable Devices in Pediatric Patients. Heart Rhythm. 2021. doi:10.1016/j.hrthm.2021.07.038.

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