Epicardial Cardiac Pacing Linked With Greater Pacemaker-Lead Failure in Children

In pediatric patients with atrioventricular block, epicardial pacemakers may increase risk for pacemaker-lead failure.

Epicardial pacemakers may be associated with increased pacemaker-lead failure in children, according to findings published in Pediatric Cardiology.

Investigators sought to compare incidence of pacemaker-lead-related complications, hemothorax and venous occlusion, and mortality between epicardial and endocardial pacemakers in children with sinus node dysfunction (SND) or atrioventricular block (AVB).

Pacemaker-lead failure (exit block, fibrosis, insulation break, or fracture leading to malfunction), infection, threshold rise, and battery depletion were the primary outcomes. Mortality and hemothorax and venous occlusion were secondary outcomes.

AVB was defined as any degree of acquired or congenital heart block resulting in delay or interruption of electrical conduction. SND was defined as electrocardiogram findings of sinus arrest for more than 2 seconds, sinoatrial block, tachycardia-bradycardia syndrome, and sinus bradycardia.

The investigators conducted a systematic review and meta-analysis searching the Web of Science, Cochrane Central Register of Controlled Trials, Scopus, PubMed, and OpenGrey databases from inception until June 2022. They included observational cohort or randomized controlled studies in English that compared clinical outcome risks between pediatric patients with SND or AVB who received epicardial pacemaker implantation vs pediatric patients who received endocardial pacemaker implantation.

Eligible studies included more than 75% children with SND or AVB and pacemaker implantation, and more than 90% of study participants were less than 18 years of age. Studies involving only 1 pacemaker type or that did not report event rates, hazard or risk ratios, or 95% confidence intervals were excluded.

The findings suggest that EPI [epicardial pacemakers] may be associated with increased PM [pacemaker]-lead failure compared to ENDO [endocardial pacemakers] while threshold rise, infection, battery depletion, and mortality rates did not differ.

Eighteen studies were included in the systematic review and 15 of those studies were included in the meta-analysis. Overall, pediatric patients (N=1348; 40% girls; mean implantation age, 6.8 years) received epicardial or endocardial implantation. Among this patient population, 40.2% had a congenital heart disease diagnosis. The most common indications for pacemaker implantation were congenital AVB (43.2%), acquired AVB (34.2%), and SND (18%).

Epicardial pacemakers were significantly associated with a higher possibility of pacemaker-lead failure (pooled odds ratio, 3.00; 95% CI, 2.05-4.39; I2=0.0%). There were no differences found between pacemaker types for the outcomes of post-implantation infection, possibility for threshold rise, or battery depletion.

Additionally, there was no difference in mortality rates between the epicardial and endocardial groups. Results between the 2 pacemaker types remained consistent through sensitivity analyses.

Included studies were overall of moderate quality with no publication bias.

Limitations of the study include only observational studies were analyzed and there is no comparison between dual and single chamber pacemakers. There is also between-study heterogeneity.

“The findings suggest that EPI [epicardial pacemakers] may be associated with increased PM [pacemaker]-lead failure compared to ENDO [endocardial pacemakers] while threshold rise, infection, battery depletion, and mortality rates did not differ,” investigators wrote. “…more longitudinal multidisciplinary studies are required to validate our results.”


Patsiou V, Haidich AB, Baroutidou A, Giannopoulos A, Giannakoulas G. Epicardial vs endocardial pacing in pediatric patients with atrioventricular block or sinus node dysfunction: a systematic review and meta-analysis. Pediatr Cardiol. Published online July 22, 2023. doi:10.1007/s00246-023-03213-x