Epicardial versus endocardial permanent pacing in adults with congenital heart disease

Background: Permanent pacing (PM) in patients with congenital heart disease (CHD) presents unique challenges - with little known about the long-term outcomes. Methods: Pacemaker complications and reinterventions were reviewed over a 38-year period and were grouped by epicardial or endocardial approaches. Results: 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. Conclusions: 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.