Safety and Feasibility of Implanting Dual-Chamber Permanent Pacemakers in Patients Under 3 kg

Purpose: Permanent pacing in the young pediatric population can be challenging, especially in small neonates. We describe our institutional experience with the surgical placement of dual-chamber permanent pacemaker (PPM) systems in neonates weighing <3 kg at the time of implantation. Methods: The Cincinnati Children's Hospital database was used to identify patients who had an epicardial dual-chamber PPM and weighed <3 kg at implantation from 2000 to 2022. Descriptive analyses focused on surgical techniques, postimplant complications, and survival. Results: Twenty patients underwent dual-chamber PPM implantation. Median age at implantation was 6.0 days [3.0-27.0], weight 2.6 kg [2.2-3.0], with the smallest being 1.9 kg. Eight of 20 patients (40%) were premature (<37 weeks), and 2/20 (10%) had Trisomy 21. Most implantations were via median sternotomy [17/20 (85%)]. Most had generator placement in the left upper quadrant [13/20 (65%)] above the posterior fascia and below the rectus muscle. Surgical indication for implantation was congenital heart block [18/20 (90%)], of which 4/18 (22%) were due to maternal lupus. Two patients had PPM secondary to postoperative heart block and 3/20 (15%) had emergent temporary epicardial wires placed before PPM. Pacemaker-related complications occurred in 1/20 (5%) patient on postoperative day 20 related to minor wound dehiscence, without infection, leading to a dual-chamber PPM exchange for a single-chamber device. Another patient (5%) developed a seroma requiring drainage on postoperative day 16. There were no PPM-related in-hospital mortalities or other complications, including late PPM infections. Conclusions: Dual-chamber epicardial PM implantation in neonates <3 kg is feasible with minimal complications and good outcomes based on our reported technique.