Transatrial lead implantation in a 12 year old boy with complex cardiac malformations. He had several open heart procedures and finally in 1995 a modified Fontan procedure with the addition of a fenestrated atrial baffle was accomplished. Sick sinus syndrome with bradycardia and dizziness was diagnosed in 2001. Because of the caval pulmonary connection a venous approach for lead insertion from cranial was impossible. Therefore, after median sternotomy a bipolar screw-in lead was implanted transatrially into the venous system (1) together with a right ventricular epicardial bipolar, steroid-eluting epicardial electrode (2). The pacemaker was programmed to DDDR mode, with the AV-conduction time so long that  intermittent atrial pacemacer stimulation allowed physiologic stimulation of the ventricle. As an atrial back up lead a second epicardial bipolar steroid-eluting electrode was placed on the right atrium (3) with the lead body tunnelled to the generator pocket. In case of transatrial lead failure (e.g. exit block), revision would not neccessitate a rethoracotomy, but only an incision into the abdominal generator pocket and the exchange of the epicardial atrial lead.