Delivery-room transcutaneous pacing and ECMO support in the NICU for a preterm neonate with congenital complete heart block

Abstract

Congenital complete heart block (CCHB) is a rare condition that may lead to severe bradycardia and hemodynamic instability at birth, particularly in preterm infants with limited myocardial reserve. The use of transcutaneous pacing (TCP) in the delivery room has rarely been reported in neonates with CCHB, and extracorporeal membrane oxygenation (ECMO) during neonatal intensive care has sporadically been described. We report a preterm infant with antenatally diagnosed isolated CCHB who developed severe bradycardia and hemodynamic compromise immediately after birth despite adequate ventilation. Emergency TCP achieved prompt electrical capture and rapid hemodynamic stabilization in the delivery room. During attempted early permanent pacemaker implantation in the Neonatal Intensive Care Unit (NICU), the patient developed intraoperative cardiorespiratory arrest requiring venoarterial ECMO support and placement of a temporary epicardial pacing system. After myocardial recovery, a permanent pacemaker was successfully implanted, and the infant was discharged with normal ventricular function. TCP may provide rapid hemodynamic stabilization in the delivery room for neonates with life-threatening bradycardia due to CCHB, and it may serve as a bridge to more definitive pacing modalities. This case suggests that a stepwise stabilization approach may be considered in critically unstable neonates with CCHB, incorporating delivery-room transcutaneous pacing followed by extracorporeal support in the NICU to allow deferred definitive pacing. In selected critically unstable patients, ECMO may provide life-saving support during surgical intervention.