Integrated Multimodal Imaging for Transvenous Transpulmonary Atrial Pacing Lead Implantation in Fontan Patient

Background

Pacemaker placement in Fontan patients is challenging owing to lack of venous continuity with the atrial and ventricular myocardium. The standard epicardial approach is complicated by the need for repeat sternotomy or thoracotomy as well as the overall long-term risk of lead failure. Transvenous lead implant has been described, but this requires transpulmonary or transbaffle puncture, which have risks of bleeding and pericardial effusion.

Case Summary

We describe a case in which multimodal imaging with fluoroscopy, computed tomography, intracardiac echocardiography, and three-dimensional electroanatomical mapping were combined to perform successful transvenous transpulmonary epicardial atrial lead placement in an extracardiac Fontan patient with protein-losing enteropathy.

Discussion

This approach can be considered as an alternative to epicardial lead placement in Fontan patients who are at moderate to high risk with the standard epicardial approach.

Take-Home Messages

Congenital heart patients with extracardiac Fontan repairs pose unique technical challenges to pacemaker implantation given the lack of venous continuity with the myocardium. The transvenous, transpulmonary approach to epicardial atrial lead placement can be considered in high-risk extracardiac Fontan patients, using integrated multimodal imaging techniques to maximize safety and success.