P1816Leadless pacemaker implantation in an 11 years old patient with recurrent vagal syncope events and documented sinus pauses

Abstract

Though vagal syncope is known to be a self limiting phenomenon with no sequelae later in life, a vagal origin of sudden death has been hypothesized. We present a case of an 11 y.o. boy with recurrent syncope, documented sinus pauses & family history of sudden cardiac death who underwent a leadless PM implantation. Results: OA was presented at the age of 9 y.o. after his 14 y.o. brother has passed away unexpectedly while playing a video game one week after a post exercise syncope. OA's ECG, Holter monitor & stress test were all concluded normal. An Epinephrine challenge test showed bidirectional VT as soon as a 0.01 mcg/kg bolus was given. It shortly organized into a uniform monofocal VT & resolved spontaneously. The family underwent through genetic consultation but no arrhythmic predisposition was found. Treatment with beta blockers was initiated & repeated Holter monitors & stress tests were all normal. One year later OA had a syncope event during school time & a subcutaneous Reveal Linq insertable monitor was implanted. Six months later, while asymptomatic, a 9 second pause was documented during sleep, his treatment was unchanged. Lately OA experienced syncope during class, this time an 18 sec. sinus pause was documented. In view of the family history, with no repeated arrhythmia ever documented, beta blockers were stopped & a PM implantation was recommended & performed. Height of 160 cm & weight of 65 kg allowed a leadless Medtronic Micra implantation. During implantation, initial contrast fluoroscopy estimated the IVC diameter at 11 mm, which was compatible with the 27F delivery system. Under fluoroscopic guidance the PM was placed in the RV apex. After showing 3 tines attached, good sensing & pacing thresholds the device was released. Pacing was set at VVI 40, the minimal pacing needed. AO was discharged a day after the implantation in good condition. Discussion: PM implantation due to vagal syncope is controversial. Lead fracture & pocket infections are the major complications in children. Its small size enables the leadless PM to be implanted in the young. This allows sparing of the veins during puberty & normal participation in sports without restrictions, avoiding the above complications while protecting during severe vagal episodes. Once grown different pacing systems should be considered.