Epicardial versus endocardial permanent pacing in adults with congenital heart disease

Permanent pacing (PM) in patients with congenital heart disease (CHD) presents unique challenges-with little known about the long-term outcomes. Pacemaker complications and reinterventions were reviewed over a 38-year period and were grouped by epicardial or endocardial approaches. The average age at intervention was 37 +/- 19 years for 106 patients and 259 PM procedures were performed (2.4 +/- 2 per patient). From the first PM procedure, patients were followed for 11.6 +/- 14 years. The most common indications for initial PM intervention were heart block (25%) and sinus node dysfunction (20%), yet reintervention was driven primarily by lead failure (49%). Endocardial systems were initially implanted in 73 patients (67%). Epicardial pacing was more common in patients with complex CHD (p = 0.006), cyanosis (p < 0.001), residual shunts (0.01), or Ebstein's anomaly (p = 0.01). Fifty-one devices (28%) developed lead or generator complications. Epicardial systems were most likely to develop lead failure (p < 0.0001), predominantly in the ventricular lead (p < 0.0001). Endocardial systems were found to be more durable than the epicardial systems (p = 0.023), and Ebstein's anomaly or an epicardial system was an independent predictor of lead failure. Permanent pacing in CHD is associated with considerable morbidity and the need for repeat intervention, especially in those with Ebstein's anomaly. Epicardial pacing systems appear to have a higher incidence of lead failure and are significantly less durable in this group.