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Background: Fontan surgery, a palliative procedure for single ventricle patients, often leads to the need for permanent pacing. Epicardial pacing has limitations, while transvenous pacing carries risks in the Fontan circulation. This case series introduces a novel approach of leadless pacemaker implantation in the extra‐cardiac Fontan (ECF) cohort to overcome these limitations. Methods: The study includes four cases of leadless pacemaker (Micra™) implantation in patients with ECF. Procedures were performed under general anesthesia with guidance from trans‐esophageal echocardiography. Various access routes were used, including trans‐carotid and trans‐fenestration approaches. Procedural details, parameters, and follow‐up data were collected. Results: All leadless pacemaker implantations were successful, with satisfactory electrical parameters and stable pacing postprocedural outcomes during short‐term follow‐up. One patient required closure of their fenestration for symptomatic desaturation post procedurally. Conclusions: Leadless pacemaker implantation via trans‐carotid and trans‐fenestration approaches appears to be a feasible back up option for pacing in Fontan patients where other options have been exhausted or there is a patient choice to avoid surgery. These techniques provide an option to avoid leaded systems or epicardial pacing, reducing the need for multiple thoracotomies and addressing challenges associated with surgical pacing leads. Further studies are needed to evaluate long‐term outcomes and assess the broader application of leadless pacemakers in the Fontan population. [ABSTRACT FROM AUTHOR]

Postoperative atrial fibrillation (POAF) is an ongoing complication following cardiac surgery, with an incidence of 15%–60%. It is associated with substantial mortality and morbidity, as well increased hospital stays and healthcare costs. The pathogenesis is not fully understood, but the literature suggests that POAF occurs when transient, postoperative triggers act on vulnerable atrial tissue produced by preoperative, procedure-induced and postoperative processes such as inflammation, oxidative stress, autonomic dysfunction and electrophysiological remodelling of the atrial tissues. This sets the stage for arrhythmogenic mechanisms, such as ectopic firing secondary to triggered activity and re-entry mechanisms generating POAF. Preoperative factors include advanced age, sex, ethnicity, cardiovascular risk factors, preoperative drugs, electrocardiogram and echocardiogram abnormalities. Procedural factors include: the use of cardiopulmonary bypass and aortic cross clamp, type of cardiac surgery, use of hypothermia, left ventricular venting, bicaval cannulation and exclusion of the left atrial appendage. Postoperative factors include postoperative drugs, electrolyte and fluid balance and infection. This review explores the pathogenesis of POAF and the contribution of these perioperative factors in the development of POAF. Patients can be risk stratified for targeted treatment and prophylaxis, and how these factors can be attenuated to improve POAF outcomes following cardiac surgery. [ABSTRACT FROM AUTHOR]