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Introduction Vein of Galen malformations (VOGM) are congenital brain arteriovenous malformations which may present with high-output heart failure in neonates. In neonates who fail maximal medical therapy for cardiopulmonary support, staged endovascular embolization may be performed to reduce the degree of arteriovenous shunting. Neonatal embolization is particularly challenging and procedural complication risks decrease significantly by 4-6 months of age. The high-flow shunting makes placement of embolic material challenging and adjunctive flow control techniques are often utilized to maximize successful embolization. Reversible systemic hypotension, often by pharmacologic means in VOGM patients, may be induced to control blood pressure and permit stable flow for successful embolization. Rapid ventricular pacing (RVP) offers robust and improved blood pressure control and has increased in use as a flow control technique for neuroendovascular procedures. Here, we describe our experience with RVP-assisted embolization of neonatal VOGM.Methods A single-center retrospective review of a prospectively maintained database identified all neonatal patients with an angiographically confirmed VOGM who underwent RVP-assisted embolization. Clinical and procedural data were extracted from electronic medical records, including demographics, presentation, procedural details, and outcomes. Procedures were performed under general anaesthesia with neurophysiological monitoring. Arterial access was obtained via femoral or umbilical artery, and embolization was performed using high concentration n-butyl cyanoacrylate (n-BCA). The RVP catheter was placed via the femoral vein. The right ventricle was paced from 150 to 270 bpm, and end-tidal CO2 was monitored as a non-invasive indicator of cardiac output.Results Eight neonates with diagnosed VOGM-related heart failure underwent 10 RVP-assisted transarterial embolization. All patients presented with choroidal VOGM. The cohort was 50% male, and the median age at embolization was 1 day. All patients presented with refractory heart failure requiring respiratory support. Other presenting symptoms included pulmonary hypertension (37.5%), seizures (37.5%), hydrocephalus (12.5%) and anuria (12.5%). RVP was performed successfully in all procedures, successfully facilitating delivery of n-BCA to the selected feeding vessel, and no intraprocedural complications occurred. After the procedure, zero (0%) patients developed with focal neurological deficits or persistent dysrhythmias. Two (25%) neonates later passed away, one due to renal failure and the other due to complications associated with a subsequently diagnosed genetic syndrome.Conclusion This series of RVP-assisted embolization of VOGM demonstrates a high degree of safety and efficacy for management in a critically ill patient cohort, even in the neonatal period. RVP is a viable strategy to consider for adjunctive flow control in neonatal embolization.Disclosures E. Pareek: None. B. Love: None. R. Pass: None. M. Geiger: None.