Choosing a device after high-grade atrioventricular block in pediatric patients

INTRODUCTION: Pediatric patients with high-degree or complete atrioventricular block require permanent pacing. Pacing in this population is challenging due to changes in age, body and heart size, vascular anatomy, associated congenital abnormalities, physical activity, and expected long-term pacing needs. AREAS COVERED: This review evaluates recommendations, strategies, limitations, and complications of pediatric pacing, based on a comprehensive literature search (PubMed, using keywords as cardiac pacing, children, pacing complications, etc.). Currently, no pacing devices or leads are specifically designed for children; adult systems are adapted for pediatric use. Recommendations and strategies vary according to age, size, and associated congenital heart defects. Guidelines published between 2021 and 2023 provide updated recommendations. Advances in tools and techniques have improved management of pediatric bradyarrhythmias. Both transvenous and epicardial pacing systems can be implanted, with generally good outcomes, although complications remain relatively frequent. EXPERT OPINION: Cardiac pacing in children is effective and safe, but no single approach fits all patients. Implantation strategies, device selection, and techniques should be individualized based on patient characteristics, anatomy, and long-term needs. Future improvements in device design, lead technology, and procedural approaches will further optimize outcomes and reduce complications in this population.