Pacing indication and patient selection for pacemaker

17-10-2020

Raja Selvaraj, JIPMER

Outline

  • Indications for pacing
  • Pacing mode selection

References

  • ACC/AHA Guidelines for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices (1998)
  • ACC / AHA / HRS guideline - Evaluation and management of patients with bradycardia and conduction delay (2018)
  • ESC guidelines - Cardiac pacing and CRT (2013)

ACC/AHA Guidelines for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices: Gabriel Gregoratos et al. Circulation 1998;97:1325–1335

2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay. JACC Volume 74, Issue 7, August 2019 DOI: 10.1016/j.jacc.2018.10.044

Brignole M, et al. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Rev Esp Cardiol (Engl Ed). 2014 Jan;67(1):58. doi: 10.1016/j.rec.2013.11.003.

Broad Indications

  • Bradycardia / Risk of future bradycardia
  • Symptoms or risk of death
  • Irreversible

guidelines_1998.png

Sinus bradycardia

Class I

  • Symptomatic bradycardia
  • Symptomatic chronotropic incompetence

Importance of symptoms

  • Never need to treat asymptomatic sinus bradycardia
  • Presence of symptoms not enough - correlate with bradycardia

Rule out systemic causes

  • Physiologic bradycardia
  • Hypothyroidism
  • Drug therapy (essential drugs which cannot be stopped or whose dose cannot be reduced exempted)

Class IIa

  • Sinus bradycardia, rate < 40, association with symptoms unclear

Generally dont pace

  • Asymptomatic bradycardia (IIb - Awake HR < 30)
  • Symptoms clearly documented to be not related to bradycardia

Holter interpretation

  • Correlate with symptoms
  • Distinguish awake rate from asleep rate
  • Pauses not important

ESC guidelines

esc_snd.png

Brignole M, et al. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Rev Esp Cardiol (Engl Ed). 2014 Jan;67(1):58. doi: 10.1016/j.rec.2013.11.003.

Acquired adult AV block - Third degree

Class I

  • Third degree AV block with symptoms (irrespective of level, rate)
  • Third degree AV block without symptoms
    • Awake rate < 40
    • Awake, pause > 3 seconds
    • Post ablation
    • Post operative, not expected to resolve
    • Neuromuscular diseases

Class IIa

  • Asymptomatic, awake rate > 40

Acquired adult AV block - Second degree

Class I

  • Second degree AV block with symptomatic bradycardia (irrespective of level, type)

Class II

  • Asymptomatic type II
  • Asymptomatic intra- or infra-His AV block (incidental at EPS)

ECG identification

2to1_suprahis.jpeg

ECG identification

second_degree_type2.jpg

EPS

suprahis.jpg

Intra-His AV block

2to1_intra_his.jpg

Intra-His AV block

2to1_intra_his2.jpg

AV block - First degree

Class II a

  • Symptoms of pacemaker syndrome, alleviation with temporary pacing

pseudo_pacemaker.jpg

Kandaswamy PK .. Selvaraj RJ. Heart failure and pulsus alternans: an unusual presentation of first-degree heart block. Circ Heart Fail. 2014 Jan;7(1):227-8. doi: 10.1161/CIRCHEARTFAILURE.113.000945. PMID: 24449815.

pseudo_pacemaker2.jpg

Kandaswamy PK .. Selvaraj RJ. Heart failure and pulsus alternans: an unusual presentation of first-degree heart block. Circ Heart Fail. 2014 Jan;7(1):227-8. doi: 10.1161/CIRCHEARTFAILURE.113.000945. PMID: 24449815.

Bifascicular / trifascicular block

Class IIa

  • Syncope, other causes excluded
  • HV > 100 ms (incidental in EPS)
  • Pacing induced Infra-His block, not physiological during EPS

Infra-His block - tracings

infra_his.png

Selvaraj RJ, Kumar B, Rangasamy S. Infra-His Block during Atrial Pacing-Functional or Pathological? Pacing Clin Electrophysiol. 2017 Jan;40(1):69-71. doi: 10.1111/pace.13001.

Infra-His block - tracings

infra_his2.png

Selvaraj RJ, Kumar B, Rangasamy S. Infra-His Block during Atrial Pacing-Functional or Pathological? Pacing Clin Electrophysiol. 2017 Jan;40(1):69-71. doi: 10.1111/pace.13001.

Post MI AV block

  • Persistent, symptomatic second or third degree AV block
  • Persistent second or third degree AV block - infranodal
  • Transient infranodal block with bundle branch block

ESC guidelines

esc_avb.png

Brignole M, et al. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Rev Esp Cardiol (Engl Ed). 2014 Jan;67(1):58. doi: 10.1016/j.rec.2013.11.003.

Miscellaneous

Neurocardiogenic syncope

  • Carotid sinus hypersensitivity - reproducible - Class I
  • Carotid sinus hypersensitive response and recurrent syncope - class IIa
  • Neurally mediated syncope with significant bradycardia during HUTT - class IIb

ESC - Reflex syncope

esc_reflex_syncope.png

Brignole M, et al. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Rev Esp Cardiol (Engl Ed). 2014 Jan;67(1):58. doi: 10.1016/j.rec.2013.11.003.

Congenital heart block

  • Symptoms - Class I
  • Ventricular dysfunction - Class I
  • Wide QRS escape - Class I
  • Rate < 50-55 in infant, < 70 with congenital heart disease
  • Rate < 50 beyond infancy - Class IIa
  • LQTS with AV block

LQTS with AV block

lqts_av_block.jpg

Mode selection

Sinus bradycardia - Recommendations (1)

  • Atrial based pacing recommended over single chamber ventricular pacing - Class I
  • Without AV conduction abnormalities, dual chamber pacing or single chamber atrial pacing - Class I
  • Program dual chamber pacing to minmize ventricular pacing

2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay. JACC 2018; 74(7), DOI: 10.1016/j.jacc.2018.10.044

AV block

  • VVI reasonable if frequent ventricular pacing not expected or multiple comorbodities - Class I
  • EF < 50% and expected pacing > 40%, consider pacing with more physiologic activation - Class IIa

ESC - VVI vs DDD

esc_vvi_ddd.png

Brignole M, et al. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Rev Esp Cardiol (Engl Ed). 2014 Jan;67(1):58. doi: 10.1016/j.rec.2013.11.003.

Rate response

  • Sinus node dysfunction - Randomized to DDD vs DDDR
  • No difference in exercise time, activity scale or QOL at 6 mths and 1 year

Lamas G.A., Knight J.D., Sweeney M.O., et al. (2007) Impact of rate-modulated pacing on quality of life and exercise capacity–evidence from the Advanced Elements of Pacing Randomized Controlled Trial (ADEPT). Heart Rhythm 4:1125–1132

Rate response summary

  • Useful in single chamber pacing (VVIR for CHB, AAIR for SND)
  • Not shown better in DDD

Summary

  • In SND pace only when symptomatic
  • In AVB, pace if symptomatic, or block below node
  • In SND, DDD superior to VVI, may be better than AAI in selected patients
  • In AVB, DDD may be slightly better than VVIR

References

  • ACC/AHA Guidelines for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices (1998)
  • ACC / AHA / HRS guideline - Evaluation and management of patients with bradycardia and conduction delay (2018)
  • ESC guidelines - Cardiac pacing and CRT (2013)

ACC/AHA Guidelines for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices: Gabriel Gregoratos et al. Circulation 1998;97:1325–1335 https://doi.org/10.1161/01.CIR.97.13.1325Circulation.

2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay. JACC Volume 74, Issue 7, August 2019 DOI: 10.1016/j.jacc.2018.10.044

#+beginreference Brignole M, et al. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Rev Esp Cardiol (Engl Ed). 2014 Jan;67(1):58. doi: 10.1016/j.rec.2013.11.003.