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This study evaluates the feasibility and outcomes of transmural placement of endocardial leads (TML) in patients with congenital heart disease.Between October 2009 and May 2015, 29 TML procedures were performed in 27 patients. Leads are grouped according to their pacing site: atrial (TML-A, n = 24) or ventricular (TML-V, n = 12). The TML-V includes transatrial and transventricular approaches. Clinical outcome, functional properties of TML, and Kaplan-Meier freedom from lead dysfunction were evaluated.Median age was 4 years (range, 29 days to 43 years). Median follow-up duration was 2 years (range, 1 day to 5.7 years). There was no early mortality. Three late deaths were observed (2 unrelated, 1 related to pacing). In group TML-A, no lead dysfunction was noted. In group TML-V, there were 3 lead dislodgements and 1 lead fracture. Kaplan-Meier freedom from lead dysfunction after 0.5, 1, and 5 years, respectively, was 100% in group TML-A and 82% ± 11%, 73% ± 13%, and 59% ± 17% in group TML-V (log rank p0.01). Mean acute (at implantation) and chronic (at last follow-up) sensing thresholds were 3.1 ± 2.3 mV and 3.5 ± 2.5 mV in group TML-A and 11.6 ± 4.9 mV and 7.5 ± 4.6 mV in group TML-V, respectively. Mean acute and chronic pacing thresholds at 0.5 ms were 1.1 ± 0.6 V and 0.6 ± 0.3 V in group TML-A and 1.0 ± 0.6 V and 0.9 ± 0.5 V in group TML-V, respectively.The transmural approach provides an alternative method in patients with congenital cardiac defects who cannot receive transvenous leads and who have extensive epicardial scarring. Subanalysis shows superior midterm performance for TML-A compared with TML-V.

Background . Due to the limited availability of homografts, different alternatives are used for replacement of the pulmonary valve. This study investigates the value of porcine stentless pulmonary xenografts in pediatric cardiac patients. Methods . Twenty-three pediatric xenograft (size 10 to 21 mm) recipients were compared with 23 homograft (size 9 to 21 mm) recipients. Results . Hospital mortality was 2 of 23 patients in the xenograft group and 3 of 23 in the homograft group (NS). Six out of 20 xenografts and 1 of 19 homografts were stenotic after 1 year ( p = 0.011). Xenograft stenoses were mainly located at the distal anastomosis, while the leaflets were preserved. Homografts showed valvular stenoses and wall calcification. The 1 year freedom from reoperation was 77% in the xenograft and 93% in homograft recipients (NS), and from transcatheter intervention 84% and 100% ( p = 0.004), respectively. Transcatheter intervention in 7 xenograft patients and 1 homograft recipient improved stenosis gradients from 65 to 40 mm Hg (mean) in 6 out of 8 patients. Explanted xenografts showed a loss of elastic membranes and proliferating connective tissue scares coated with activated endothelium. Conclusions . Xenografts demonstrated a higher incidence of supravalvular obstructions, which were possibly due to unfavorable hemodynamics at the distal anastomosis. Histological findings additionally indicated a pronounced immunological response. Interventional angioplasty lowered the rate of reoperation. Thus, the use of xenografts in children can be accepted as a second choice when a homograft is unavailable.

Background . The role of peritoneal dialysis (PD) in the management of infants after heart operation is under discussion. The aim of this study was to investigate the effect of PD on fluid balance and outcome. Methods . Twenty-seven (33%) of 81 consecutive infants who underwent heart operation required PD. In 22 patients (81%), PD was started prophylactically at the end of the operation. We recorded hemodynamic data and fluid balance. Patients experiencing acute renal failure (ARF) were compared with the remaining infants. Results . Eleven of 81 patients (14%) experienced ARF; 3 of them died (4% of all patients undergoing operation, 27% of those with ARF). Complications of PD, present in 33%, were transitory and of minor significance. Patients with ARF had decreased cardiac function compared with those without ARF but similar fluid balance. Conclusions . Peritoneal dialysis is an effective and safe method for the treatment of ARF in infants after open heart operation. As PD is helpful in modulating postoperative fluid balance, prophylactic use of PD can be recommended for selected patients who are at risk for low cardiac output syndrome.

An 8-year-old (35 kg) boy presented with progressive right ventricular outflow tract enlargement (28 mm) and progressive tricuspid regurgitation after transannular repair of tetralogy of Fallot and was scheduled for pulmonary valve replacement. To spare reoperation on full sternotomy, a transverse mini-thoracotomy through the third intercostal space was used to implant an injectable 29-mm stented porcine valve directly through an incision of the pulmonary artery bifurcation. The procedure was performed while rapid ventricular pacing and right ventricular unload by a short running femorally implanted cardiopulmonary bypass. The stented valve was fixed with three single sutures to avoid embolization. The interventional result was well with full competence of the valve. The boy was discharged at day 4 after the procedure.