Guidelines
- ACC/AHA Guidelines for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices: Executive Summary. Circulation. 1998;97:1325–1335 https://doi.org/10.1161/01.CIR.97.13.1325
- 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. J Am Coll Cardiol 2018
- 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. European Heart Journal, Volume 42, Issue 35, 14 September 2021, Pages 3427–3520, https://doi.org/10.1093/eurheartj/ehab364
Asymptomatic acquired AV block
56 M, Routine check up, denies any symptoms
1998 guidelines
- Class I
- Awake rate < 40
- Awake, pause > 3 seconds
- Post ablation
- Post operative, not expected to resolve
- Neuromuscular diseases
- Class II a
2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. European Heart Journal, Volume 42, Issue 35, 14 September 2021, Pages 3427–3520
Paroxysmal AV block
A curious alliance: Sinus nodal dysfunction precipitating atrioventricular block. SreekanthYerram, MDChandramohanRamasamy, MDJayaramanBalachander, MD, DMRaja J.Selvaraj, MD. Journal of Arrhythmia Volume 30, Issue 3, June 2014, Pages 208-210
2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. European Heart Journal, Volume 42, Issue 35, 14 September 2021, Pages 3427–3520
A curious alliance: Sinus nodal dysfunction precipitating atrioventricular block. SreekanthYerram, MDChandramohanRamasamy, MDJayaramanBalachander, MD, DMRaja J.Selvaraj, MD. Journal of Arrhythmia Volume 30, Issue 3, June 2014, Pages 208-210
A curious alliance: Sinus nodal dysfunction precipitating atrioventricular block. SreekanthYerram, MDChandramohanRamasamy, MDJayaramanBalachander, MD, DMRaja J.Selvaraj, MD. Journal of Arrhythmia Volume 30, Issue 3, June 2014, Pages 208-210
First degree AV block
Does this patient need pacing ?
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.
2:1 AV block
Asymptomatic - Diagnosis, level, management ?
Bifascicular / trifascicular block and Syncope
54M with syncope
2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. European Heart Journal, Volume 42, Issue 35, 14 September 2021, Pages 3427–3520
2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. European Heart Journal, Volume 42, Issue 35, 14 September 2021, Pages 3427–3520
Asymptomatic sinus node dysfunction
Asymptomatic 22 yr old male
2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. European Heart Journal, Volume 42, Issue 35, 14 September 2021, Pages 3427–3520
2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. European Heart Journal, Volume 42, Issue 35, 14 September 2021, Pages 3427–3520
2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. European Heart Journal, Volume 42, Issue 35, 14 September 2021, Pages 3427–3520
Supraventricular tachycardias (prevent, treat)
Patient with episodic presyncope
MINERVA trial
Giuseppe Boriani et al. Atrial antitachycardia pacing and managed ventricular pacing in bradycardia patients with paroxysmal or persistent atrial tachyarrhythmias: the MINERVA randomized multicentre international trial, European Heart Journal, Volume 35, Issue 35, 14 September 2014, Pages 2352–2362
2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. European Heart Journal, Volume 42, Issue 35, 14 September 2021, Pages 3427–3520
Long QT syndrome
Newborn - after delivery for fetal bradycardia
2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. European Heart Journal, Volume 42, Issue 35, 14 September 2021, Pages 3427–3520
Reflex syncope
2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. European Heart Journal, Volume 42, Issue 35, 14 September 2021, Pages 3427–3520
Asymptomatic Congenital Heart Block
5 year old, incidentally detected bradycardia
- Mean daytime HR < 50
- Pause > 3 times CL of escape rhythm
- Wide QRS escape
- Prolonged QT interval
- Complex ectopy
- Ventricular dysfunction (attributed to bradycardia)
Weigh pros and cons
- Transvenous pacing > 10 kg
- Lifelong requirement for pacing, multiple leads
- Growth spurts
Hypertrophic Obstructive Cardiomyopathy
2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. European Heart Journal, Volume 42, Issue 35, 14 September 2021, Pages 3427–3520
Take Home
- Acquired AV block - Pace always (regardless of symptoms, except above His)
- Bundle branch block and syncope - High index of suspicion, history important
- Sinus node dysfunction - Never pace unless symptoms
- Pacing may rarely help - HCM, reflex syncope, LQTS