Main Reference ACCAHAHRS 2008 Guidelines for DeviceBased Therapy of Cardiac Rhythm Abnormalities a report of the American College of CardiologyAmerican Heart Association Task Force on Practice Guidelines Writing Committee to Revise the ACCAHANASPE 2002 Guideline Update for Implantation of C ID: 784732
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Slide1
Pacing in Bardyarrhythmia
Slide2Main ReferenceACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and
Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons.
Circulation. 2008 May 27;117(21):e350-408.
Indications for Pacing
Slide3Complete (3rd degree AV block)
Complete A V dissociation, regular R waves, Atrium>VentricleSecond degree AV blockMobitz
I (
Wenckebach)Progressive increase in PR interval before block
Shortening of RR intervals P-P equal (*ventricular phasic dysrhythmia)
Mobitz IIFixed PR interval before and after block, can be high grade (≥2 non-conducted P waves) or 2:1.First degree AV blockPR interval >200ms
Indications for Permanent pacing in
Aquired
Atrioventricular
Block
Slide4Third degree or second degree block:Class 1 indication for pacing if:
Bradycardia associated with symptomsNeed for drug therapy resulting in symptomatic bradycardia
Asymptomatic with pause >3.0s or escape <40bpm or broad complex escape (below level of AV node)
Asymptomatic with AF and pause >5.0secs
Asymptomatic but associated neuromuscular disease
Block occurring during exercise regardless of presence of ischaemia.Permanent pacing is
Indicated
in
Aquired
Atrioventricular
Block
Slide5Class IIa recommendationsAsymptomatic adults, resting rate >40bpm and without structural heart disease.
Asymptomatic adults with level of block discovered below the AV node at electrophysiological study
Symptoms of pacemaker syndrome
Asymptomatic type II AV block with narrow QRS (note wide QRS makes this class I indication
)
Permanent pacing is Reasonable in Aquired Atrioventricular
Block
Slide6Pacing is not indicated or is harmful for the following:Asymptomatic 1st
degree heart blockAsymptomatic Mobitz type 1
Wenckebach
Transient or unlikely to recur, during episodes of hypoxia in the sleep apnoea syndromes.
Permanent pacing is
Not Indicated in Aquired
Atrioventricular
Block
Slide7Why do we need pacing in AV block?
Unpaced
group followed between 1960-1965 before pacing was introduced
i.e. Self selected ‘survivors’
From H
Sniddon
“ Death in Long-term paced patients” Br Heart Journal 1974; 36:1201-1209
Slide8Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.
Epstein, A. E. et al. J Am Coll Cardiol 2008;51:e1-e62
Selection of Pacemaker Systems for Patients With Atrioventricular Block
Slide9Class I (indicated for:)Documented symptomatic bradycardia
including frequent sinus pausesChronotropic incompetenceEssential concomitant use of rate slowing drugs
Class
IIa (Reasonable in:)
Symptoms not documented but resting HR<40bpm
Unexplained syncope and abnormal EP studyClass IIb (“may be considered in”:)Asymptomatic and resting HR ≤ 40bpm
Indications for Permanent pacing in Sick Sinus Syndrome
Slide10Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.
Epstein, A. E. et al. J Am Coll Cardiol 2008;51:e1-e62
Selection of Pacemaker Systems for Patients With Sinus Node Dysfunction
Slide11Pacing in SSS (VVI vs AAI)
HR Anderson et al. Lancet. 1997; 9086: 1210-1216
Overall Survival
Survival CVS death
Freedom from AF
Freedom from Chronic AF
Slide12Pacing in SSS (VVI vs. AAI)
Rosenqvist
et al. Am Heart J; 1988;116: 16-22
Retrospective study of 168 patients
AF significantly greater in VVI group c.f. AAI group
47%
vs
6.7%
Mortality
VVI=23%
AAI=8% (p=0.045)
Slide13Pacing in SSS (DDD vs. VVI)
Lamas et al. NEJM 2002; 346: 1854
RCT of 2010 pts with SSS
1014 DDD
996 VVI
AF developed in:
VVI 27.1%
DDD 21.4% (p=0.004)
Note still high rate of AF with V pacing in either arm
Slide14Pacing in SSS (MVP vs. DDD)
Sweeny et al. NEJM. 2007; 357: 1000-8
Comparison of minimal ventricular pacing (MVP) and conventional DDD.
RCT of 1065 patients
MVP 530
DDD 535
Primary endpoint time to
Afib
(trial stopped early as endpoint met)
AF
MVP: 7.9%
DDD: 12.7% (p=0.004)
HR 0.6 (0.41-0.88)
Slide15Ventricular pacing in SSS is bad!
Increased risk of deathIncreased risk of stroke
Increased risk of AF
DDD pacing is better
No difference in Mortality
Increased risk of AF but better than VVIAtrial based pacing is best!
Summary of data to date on pacing and SSS
DANPACE * DDD
vs
AAI
Slide16Class ISyncope with clear carotid events and CSM producing pause >3
secsClass IIa
Syncope with CSM >3secs
Class IIb
‘Significantly’ symptomatic
neurocardiogenic syncope associated with documented bradycardia spontaneously or at Tilt tableClass III (Not-indicated)Positive CSM in absence of symptoms
Situational
vasovagal
syncope
Pacing in
Hypersentive
Carotid Syndrome and
Neurocardiogenic
Syncope
Slide17102 patients followed for 7-30 yearsStokes-Adams attacks in 27; fatal in 8
First attack fatal in 6/819 survived and pacedLong QTc (>0.45s) observed in 7 – all 7 had subsequent SA attack. All 7 had previously normal QTc. 3 died, 4 paced survived.
Ventricular rate gradually decreased with age
Mitral regurgitation developed in 16 (4 died)
A PPM reduced the risk of death
Pacing for congenital AV block
Michaelsson
et al. Circulation 1995;92:442-9
Slide18CLASS I
1.
Permanent pacemaker implantation is indicated for advanced
second- or third-degree AV block associated with symptomatic
bradycardia
, ventricular dysfunction, or low cardiac output
.
(Level of Evidence: C)
2.
Permanent pacemaker implantation is indicated for
SND
with
correlation of symptoms during
age-inappropriate
bradycardia
.
The definition of
bradycardia
varies with the patient’s age and
expected heart rate.
(Level of Evidence: B) (53,86,253,257)3. Permanent pacemaker implantation is indicated for postoperativeadvanced second- or third-degree AV block that is notexpected to resolve or that persists at least 7 days after cardiacsurgery. (Level of Evidence: B) (74,209)4. Permanent pacemaker implantation is indicated for congenitalthird-degree AV block with a wide QRS escape rhythm, complexventricular ectopy, or ventricular dysfunction. (Level of Evidence: B)
(271–273)5. Permanent pacemaker implantation is indicated for congenitalthird-degree AV block in the infant with a ventricular rate lessthan 55 bpm or with congenital heart disease and a ventricularrate less than 70 bpm. (Level of Evidence: C) (267,268)Recommendations for Permanent Pacing in Children,Adolescents, and Patients With CongenitalHeart Disease
Slide19Pacing for
Atrioventricular
Block Associated
With Acute Myocardial Infarction
CLASS I
1.
Permanent ventricular pacing is indicated for persistent
second degree
AV block in the His-Purkinje system
with
alternating
bundle-branch block
or
third-degree AV block
within or below the
His-Purkinje system after ST-segment elevation MI
.
(Level of
Evidence: B)
(79,126–129,131)
2. Permanent ventricular pacing is indicated for transient advancedsecond- or third-degree infranodal AV block and associatedbundle-branch block. If the site of block is uncertain, an electrophysiologicalstudy may be necessary. (Level of Evidence: B)(126,127)3. Permanent ventricular pacing is indicated for persistent andsymptomatic second- or third-degree AV block. (Level of Evidence:C)
Slide20Recommendations for Cardiac Resynchronization
Therapy in Patients With Severe Systolic Heart Failure
CLASS I
1.
For patients who have LVEF less than or equal to
35%, a QRS
duration greater than or equal to
0.12 seconds
, and sinus
rhythm, CRT with or without an ICD is indicated for the treatment of NYHA functional
Class III
or ambulatory
Class IV
heart failure symptoms with optimal recommended medical therapy.
(Level of
Evidence: A)
(222,224,225,231)
Slide21IPG
Basic Biomechanics of Pacing
Right Atrial Lead
Implantable Pulse generator
(
CAN)
Right Ventricular Lead
Left Ventricular Lead
Slide22Basic Biomechanics of Pacing
Unipolar
Large Spike on ECG
Bipolar
Small Spike on ECG
Circuit between Lead tip and IPG
Circuit between two poles at the end of the lead
IPG
Slide23Slide24Slide25Slide26Slide27Slide28Slide29RV Lead Placement
Septal and Apical
Apical
Slide30RV Lead Placement
RV Outflow Septum
Apical
Slide31Slide32Slide3372 year old female attends ER with episode of syncope. No prodrome.
Telemetry recording as belowWhat does the Trace show?What is the optimum treatment
Case 1
Slide3465 male admitted with seizures.
Case 2
Slide35Case 2
Slide36Asymptomatic 54 year old male
Case 3
Slide3724 post op
Case 4