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CLINICAL RESEARCH: CONGENITAL HEART DISEASE

Acute Hemodynamic Effects of Pacing in Patients With Fontan Physiology

A Prospective Study

Brent J. Barber, MD^_*,_*, Anjan S. Batra, MD, FACC, Grant H. Burch, MD, FACC^_*, Irving Shen, MD, FACC, Ross M. Ungerleider, MD, FACC^_*, John W. Brown, MD, FACC, Mark W. Turrentine, MD, FACC, Motomi Mori, PhD^_*, Yi-Ching Hsieh, MS^_* and Seshadri Balaji, MD, FACC^_*

^_* Departments of Pediatric Cardiology, Cardiothoracic Surgery, and Public Health & Preventive Medicine, Oregon Health & Science University, Portland, Oregon
Department of Pediatric Cardiology, Indiana University, Indianapolis, Indiana

Manuscript received April 5, 2005; revised manuscript received May 24, 2005, accepted July 5, 2005.

^_* Reprint requests and correspondence: Dr. Brent J. Barber, University of Arizona Health Sciences Center, 1501 North Campbell Avenue, Tucson, Arizona 85724. (Email: barberb{at}peds.arizona.edu).

OBJECTIVES: The purpose of this research was to assess the hemodynamic response to atrial, ventricular, and dual-chamber pacing in patients with Fontan physiology.

BACKGROUND: Bradycardia, due to sinus node dysfunction or atrioventricular (AV) block, with need for pacing, is common after the Fontan operation. The optimal pacing mode for Fontan patients is unknown, but is critical, as hemodynamic aberrancies may cause severe clinical deterioration. We hypothesized that AV synchrony is vital for maximizing Fontan hemodynamics.

METHODS: A cross-over trial was conducted with 21 patients (age 2 to 18 years, median 4 years; male patients = 13) in the intensive care unit after a Fontan operation. Hemodynamic parameters, including mean left atrial pressure (LAP, in mm Hg), mean pulmonary artery pressure (PAP, in mm Hg), mean arterial blood pressure (MAP, in mm Hg), and indexed cardiac output via Fick (Qs, in l/min/m²) were measured with atrial, ventricular, and dual-chamber pacing. Measurements were made after pacing for 10 min in each mode, and a 10-min rest was given between each pacing maneuver.

RESULTS: Asynchronous ventricular (VOO) pacing resulted in significantly worse hemodynamics when compared to dual-chamber (DOO) and atrial (AOO) pacing with a higher LAP (9.4 VOO; 6.8 DOO; 5.4 AOO) and PAP (15.2 VOO; 13.5 DOO; 12.7 AOO) and lower Qs (3.0 VOO; 3.5 DOO; 3.9 AOO) and MAP (60.1 VOO; 66.5 DOO; 67.2 AOO).

CONCLUSIONS: Asynchronous ventricular pacing, after the Fontan procedure, has acute, adverse hemodynamic consequences (elevated LAP and PAP and decreased Qs and MAP).

Abbreviations and Acronyms   AOO = atrial demand pacing   AV = atrioventricular   DOO = dual-chamber demand pacing   LAP = left atrial pressure   MAP = mean arterial pressure   PAP = pulmonary artery pressure   Qs = indexed cardiac output   VOO = ventricular demand pacing