A normal heart beat is of immense importance for anyone. In the previous section, you have been introduced to those children who need a permanent pacemaker. When the decision is made, you will be faced with another choice: which doctor to see. For adults, the installation of a permanent pacemaker is, without a doubt, the job of the cardiologist. In some large cardiac centers, there is even an arrhythmia unit dedicated to pacemaker installation and commissioning. The physician can drift the pacing electrode through the peripheral vascular puncture into the right ventricle and then hook the distal end of the electrode to the endocardium. Finally, the pacemaker is installed under the anterior chest skin, and the pacing lead is connected to the pacemaker and it is ready to work. Zhang Hao, Department of Pediatric Cardiac Surgery, Fu Wai Hospital, Beijing, China However, the installation of a pacemaker is far more complicated for pediatric patients than for adults. A permanent pacemaker system consists of two aspects: the pacing lead (electrodes) and the pacemaker. In a pediatric patient, he/she is still in the developmental stage. The child grows slowly in height, but the pacing lead is a fixed length. Since the child has a small heart, it is also not possible to coil more leads in the heart or peripheral blood vessels for development. Therefore, for children, even if a permanent pacemaker can be easily installed percutaneously, they inevitably face problems with later development. The growth of the child can lead to a tear in the connection between the pacing lead and the endocardium, which can render the pacemaker non-functional. Another challenge facing pediatric permanent pacemaker installation is the issue of pacemaker power consumption. The pacemakers they use are the same for both adults and pediatric patients. With modern technological advances, pacemakers can be made very small. However, power is still the main factor limiting the life span of a pacemaker. Since adults need a slower heart rate of more than 60 beats per minute, but children need 2-3 times more, which means that the life of a pacemaker is 2-3 times shorter, and the frequency of pacemaker replacement is much higher in children than in adults. If the first pacemaker is installed under the skin of the anterior chest as in adults, the pacemaker is easily damaged due to the active nature of the child and the lack of sufficient fat protection in the anterior chest, and it is very inconvenient to keep taking and placing the pacemaker in the same position. On the other hand, many children with congenital heart disease cannot have a permanent pacemaker installed percutaneously by internal medicine due to anatomical malformations of the heart. For example, in single ventricle surgery and corrective aortic surgery, the superior vena cava is not directly connected to the right ventricle, so percutaneous installation is not possible and surgical open-heart installation is the only way for such children. From the above description, it is easy to conclude that percutaneous installation of permanent pacemakers is not a reasonable option for small infants or children, although it is feasible. Therefore, in foreign cardiac centers, the preferred surgical route for pacemaker installation in children is to make a small incision under the sternum and suture the pacing lead directly to the surface of the right ventricle (i.e., epicardial route), while the pacing lead can be easily coiled in the thoracic cavity. The current epicardial pacing lead is typically 1 m2 in length, far longer than the adult length from the subxiphoid process to the belly button, so the child’s development does not feel in any way that the lead is not long enough. A small incision is then made in the child’s belly button and the pacemaker is buried under the rectus abdominis muscle. This way the child’s thick abdominal fat pad and rectus abdominis muscle give good protection to the pacemaker. Below is a picture of a 2 year old child who was fitted with a permanent pacemaker by the author. The child was undergoing surgery to repair a ventricular septal defect at a local hospital, but a high degree of conduction block occurred after surgery. The child had a heart rate of just over 30 beats per minute, as well as longer periods of cardiac arrest with syncope. The surgery was performed with 2 small incisions, each about 2-3 cm. For children who have had combined preoperative heart disease, an epicardial pacemaker should be the first choice to be installed in the original incision because of the previous sternotomy. A small child who is fitted with a pacemaker in infancy will need to have the pacemaker replaced 7-9 times in an exhaustive lifetime, if the child grows up and lives to 80 years of age. Therefore, a better internationally accepted treatment strategy is to install a pacemaker by the epicardial route if the child is within 5 years of age. This way, when the child grows up, when the pacemaker is depleted, he or she is switched to the percutaneous route, i.e., the transvenous route for endocardial pacemaker installation during adolescence. Therefore, the installation of a pacemaker in a child is a systemic project, not only for cardiology or cardiac surgery, but for both departments to work together for the health of the child.