Transposition patient with mustard’s operation and brady-tachy issues: Case submitted by Vivienne Ezzat, MBChB

1. Atrial switch (Mustard’s and Senning’s operation) patients can have complex plumbing and electrical issues. Proactive attention to both issues is important to reduce morbidity and mortality, to maintain quality of life, and to extend their longevity as much as possible. 2. The number and size of pacing leads traversing through the superior baffle should be minimized to reduce the risk of baffle stenosis/occlusion. Baffle stenosis should be addressed before lead implantation. 3. Most patients in this group do not need ventricular pacing. Ventricular pacing can increase the risk of dyssynchrony-induced ventricular dysfunction and should be avoided if possible. 4. If ventricular pacing is unavoidable (mostly due to the rare presence of complete heart block), biventricular pacing should be considered in order to minimize dyssynchrony.