Cardiac pacing stimulates the heart and can be performed by two distinct approaches: transvenous route to access the endocardial surface and open surgical access to the epicardium. Transvenous placement of leads in small children and patients with congenital heart defects presents unique challenges to the cardiologist. The vascular space of small pediatric patients is often inadequate to accommodate pacemaker leads and delivery tools, while congenital anomalies, intracardiac shunts, venous obstruction, mechanical tricuspid valves, and endocarditis may preclude the transvenous approach in older children and adults.

Although most teenage and adult patients with structurally normal hearts are well served by transvenous pacemakers, epicardial pacing remains the standard of care for infants, small children, and those with complex congenital heart disease. Epicardial placement of leads usually requires a median sternotomy or thoracotomy to access the epicardial surfaces, and postoperative recovery entails multiple days in the hospital, usually...

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