Pacemaker and implantable cardioverter defibrillator implantation in pediatric patients

Pediatric pacing presents peculiar challenges and characteristics due to the peculiarity of children and adolescents, above all the somatic growth, but also the active lifestyle, the susceptibility to infections, and the generally anticipated long survival. In contrast, pacemaker (PM) generator and leads are designed for adult patients. Studies concerning children with PM are usually small, disomogeneous and without control groups. Large studies are rare. Moreover, concerns have been raised about long-term outcome of leads, ventricular and valvular dysfunction, venous patency, cosmetic results and psychological factors. So, it is still debated which systems have to be preferred, between the endocardial and the epicardial with steroid-eluting leads. Pediatric PM and (ICDs) show good results, but complications are still frequent, generally lead related, and often require reinterventions. As a general rule, less leads are implanted in children, less complications will occur in the future, and the simplest pacing system (generally, single-chamber PM) has better outcome. The creation of an atrial loop might allow the 'elongation' of the lead with the growth. Endocardial and epicardial pacing with steroid-eluting leads have comparable electrical performances, expecially in absence of other congenital heart defects and previous heart surgery, although endocardial pacing shows the best outcomes: it should be the first choice in children over 10-15 kg.