Indications for Permanent Pacing Joe Gallinghouse, M.D. Texas Cardiac Arrhythmia Austin, Texas

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1 Indications for Permanent Pacing Joe Gallinghouse, M.D. Texas Cardiac Arrhythmia Austin, Texas Remember the Suture!

2 Impulse Formation and Conduction Disturbances Cardiac Electrical Anatomy Sinoatrial Node

3 Cardiac Electrical Anatomy Atrioventricular Node Cardiac Electrical Anatomy Bundle of HIS

4 Cardiac Electrical Anatomy Left Bundle Branch (LBB) Posterior Fascicle of LBB Anterior Fascicle of LBB Right Bundle Branch (RBB) Symptoms- Bradyarrhythmia Syncope or pre-syncope Dizziness Congestive heart failure Mental confusion Palpitations Shortness of breath Exercise intolerance

5 Case Example 86 yo female with no prior history of cardiac disease, presents with syncope Eating lunch, fell into soup Past Med Hx: HTN, DJD Meds: ACE I Admitted to telemetry 12 lead EKG unremarkable Echo Efx 65%, moderate MR, LA 5.5 cm Telemetry Strip

6 Sinus Node Recovery Time (SNRT) Sinus Node Dysfunction Sinus bradycardia Sinus arrest SA block Brady-tachy syndrome Chronotropic incompetence

Sinus Node Dysfunction Sinus Bradycardia Persistent slow rate from the SA node. The parameters from this waveform include: - Rate = 45 bpm - PR interval = 180 ms (.

7 Sinus Node Dysfunction Sinus Bradycardia Persistent slow rate from the SA node. The parameters from this waveform include: - Rate = 45 bpm - PR interval = 180 ms (.18 seconds) Sinus Node Dysfunction Sinus Arrest 2.8-second arrest Failure of sinus node discharge resulting in the absence of atrial depolarization and periods of ventricular asystole - Rate = 75 bpm - PR interval = 180 ms (.18 seconds) second arrest

Sinus Node Dysfunction SA Exit Block 2.1-second pause Transient blockage of impulses from the SA node - Rate = 52 bpm - PR interval = 180 ms (.18 seconds) - 2.

8 Sinus Node Dysfunction SA Exit Block 2.1-second pause Transient blockage of impulses from the SA node - Rate = 52 bpm - PR interval = 180 ms (.18 seconds) second pause Sinus Node Dysfunction Bradycardia-Tachycardia (Brady-Tachy) Syndrome Intermittent episodes of slow and fast rates from the SA node or atria - Rate during bradycardia = 43 bpm - Rate during tachycardia = 130 bpm

9 Chronotropic Incompetence Max Heart Rate Slow Unstable Quick Rest Start Activity Time Stop Activity ACC/AHA Classification of Indications Class I Conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful, and effective. Class II Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. - Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. - Class IIb: Usefulness/efficacy is less well established by evidence/opinion.

10 ACC/AHA Classification of Indications Class III Conditions for which there is evidence and/or general agreement that a procedure or treatment is not useful/effective and in some cases may be harmful. ACC/AHA Classification of Clinical Evidence Evidence supporting current recommendations are ranked as levels A, B, and C: - Level A: Data derived from multiple randomized clinical trials involving a large number of individuals. - Level B: Data derived from a limited number of trials involving comparatively small numbers of patients or from well-designed data analysis of nonrandomized studies or observational data registries. - Level C: Consensus of expert opinion was the primary source of recommendation.

11 Pacing in Sinus Node Dysfunction Class I Indications 1. Sinus node dysfunction with documented symptomatic bradycardia, including frequent sinus pauses that produce symptoms. - May be a consequence of essential long-term drug therapy for which there is no alternative. 2. Symptomatic chronotropic incompetence. Pacing in Sinus Node Dysfunction Class IIa Indications 1. Sinus node dysfunction with heart rate <40 bpm, developing either spontaneously or as a result of necessary drug therapy, when a clear association between significant symptoms consistent with bradycardia and the actual presence of bradycardia has not been documented. 2. Syncope of unexplained origin when major abnormalities of sinus node function are discovered or provoked in EP studies.

12 Pacing in Sinus Node Dysfunction Class IIb Indications 1. In minimally symptomatic patients, chronic heart rates <40 bpm, while awake. Pacing in Sinus Node Dysfunction Class III Indications 1. Sinus node dysfunction in asymptomatic patients including those in whom substantial bradycardia (heart rate <40 bpm) is a result of long-term drug treatment. 2. Sinus node dysfunction in patients in whom symptoms suggestive of bradycardia are clearly documented not to be associated with a slow heart rate. 3. Sinus node dysfunction with symptomatic bradycardia due to nonessential drug therapy.

13 Case Example 67 yo male with hx HTN, moderate aortic stenosis Presents with complaint of DOE Meds: ASA, HCTZ Presenting 12 Lead EKG

14 Case Example Carotid Massage results in transient restoration of 1:1 conduction Echo unchanged from previously- Efx 60%, moderate AS AV Block First-degree AV block Second-degree AV block - Mobitz types I and II Third-degree AV block Bifascicular and trifascicular block

15 First-Degree AV Block 340 ms AV conduction is delayed, and the PR interval is prolonged (>200 ms or.2 seconds) - Rate = 79 bpm - PR interval = 340 ms (.34 seconds) Second-Degree AV Block Mobitz I (Wenckebach) ms ms ms No QRS Progressive prolongation of the PR interval until a ventricular beat is dropped - Ventricular rate = irregular - Atrial rate = 90 bpm - PR interval = progressively longer until a P-wave fails to conduct

Second-Degree AV Block Mobitz II P P QRS Regularly dropped ventricular beats - 2:1 block (2 P waves to 1 QRS complex) - Ventricular rate = 60 bpm - Atrial rate =

16 Second-Degree AV Block Mobitz II P P QRS Regularly dropped ventricular beats - 2:1 block (2 P waves to 1 QRS complex) - Ventricular rate = 60 bpm - Atrial rate = 110 bpm Third-Degree AV Block No impulse conduction from the atria to the ventricles - Ventricular rate = 37 bpm - Atrial rate = 130 bpm - PR interval = variable

17 Pacing for Acquired AV Block Class I Indications 1. Third-degree and advanced second degree AV block at any anatomic level with: a) Bradycardia and symptoms (including heart failure) presumed due to AV block, b) Arrhythmias and other medical conditions requiring drugs that result in symptomatic bradycardia, c) Documented asystole >3.0 sec. or escape rate <40 bpm in awake, symptom-free patients, d) Post AV junction ablation. Pacing for Acquired AV Block Class I Indications 1. Third-degree and advanced second degree AV block at any anatomic level with (continued): e) Postoperative AV block not expected to resolve after cardiac surgery, f) Neuromuscular diseases with AV block, with or without symptoms. 2. Second-degree AV block regardless of type or site of block, with associated symptomatic bradycardia.

18 Pacing for Acquired AV Block Class IIa Indications 1. Asymptomatic third-degree AV block at any anatomic site with average, awake ventricular rate >40 bpm, especially if cardiomegaly or LV dysfunction is present. 2. Asymptomatic type II second-degree AV block with a narrow QRS. 3. Asymptomatic type I second-degree AV block at intraor infra-his levels at EP study. 4. First or second degree AV block with symptoms similar to pacemaker syndrome. Pacing for Acquired AV Block Class IIb Indications 1. Marked first-degree AV block (>0.30 sec.) in patients with LV dysfunction and CHF in whom a shorter AV interval results in hemodynamic improvement, presumably by left atrial filling pressure. 2. Neuromuscular diseases with any degree of AV block (including first degree AV block), with or without symptoms.

Pacing for Acquired AV Block Class III Indications 1. Asymptomatic first-degree AV block. 2. Asymptomatic type I second-degree AV block at the supra-his level. 3.

19 Pacing for Acquired AV Block Class III Indications 1. Asymptomatic first-degree AV block. 2. Asymptomatic type I second-degree AV block at the supra-his level. 3. AV block expected to resolve and unlikely to recur (e.g., drug toxicity, Lyme disease, etc), or during hypoxia in sleep apnea syndrome in absence of symptoms. No Ventricular Capture

to mailbox Facial trauma 3 months prior: Echo Efx

20 Case Example 43 yo female with hx sarcoidosis Presents to ER with syncopal event while walking to mailbox Facial trauma 3 months prior: Echo Efx 55%, no significant valvular dz Presenting 12 Lead EKG

21 Finding at EPS Bifascicular Block Right bundle branch block and left posterior hemiblock

22 Bifascicular Block Right bundle branch block and left anterior hemiblock Bifascicular Block Complete left bundle branch block

23 Trifascicular Block Complete block in the right bundle branch and complete or incomplete block in both divisions of the left bundle branch Pacing for Chronic Bifascicular and Trifascicular Block Class I Indications 1. Intermittent third-degree AV block. 2. Type II second-degree AV block. 3. Alternating bundle-branch block.

24 Pacing for Chronic Bifascicular and Trifascicular Block Class IIa Indications 1. Syncope not demonstrated to be due to AV block when other likely causes have been excluded, specifically ventricular tachycardia. 2. Incidental finding at EP study of markedly prolonged HV interval (>100 ms) in asymptomatic patients. 3. Incidental finding at EP study of pacing-induced infra-his block that is not physiological. Pacing for Chronic Bifascicular and Trifascicular Block Class IIb Indications 1. Neuromuscular diseases..with any degree of fascicular block with or without symptoms, because there may be unpredictable progression of AV conduction disease.

25 Pacing for Chronic Bifascicular and Trifascicular Block Class III Indications 1. Fascicular block without AV block or symptoms. 2. Fascicular block with first-degree AV block without symptoms. Case Example 72 yo male develops recurrent near syncope Always seems to occur while dressing for church on Sundays No prior cardiac hx On no meds

26 Case Example EEG, CT/MRI head normal Echo: Efx 55%, mild AI Stress perfusion study normal Carotid Sinus Massage

27 Neurocardiogenic Syncope Carotid Sinus Syndrome (CSS/CSH) Vasovagal Syncope (VVS) Mechanisms of Neurocardiogenic Syncope Cardioinhibitory - Initiated by inappropriate drop in heart rate Vasodepressor - Symptomatic decrease in systolic blood pressure due to vasodilation Mixed - Includes components of cardioinhibitory and vasodepressor

28 Hypersensitive Carotid Sinus Syndrome (CSS) Extreme reflex response to carotid sinus stimulation Results in bradycardia and/or vasodilation Can be induced by: - Tight collar - Shaving - Head turning - Exercise - Other activities that stimulate the carotid sinus Vasovagal Syncope (VVS) Neurally mediated transient loss of consciousness Can be precipitated by: - Fear, anxiety - Physical pain or anticipation of trauma/pain - Prolonged standing Symptoms include: - Dizziness - Blurred vision - Weakness - Nausea, abdominal discomfort - Sweating

29 Vasovagal Syncope Pacing in CSS and VVS Class I Indications 1. Recurrent syncope caused by carotid sinus stimulation; minimal carotid sinus pressure induces ventricular asystole >3 sec duration in absence of any medication that depresses the sinus node or AV conduction.

30 Pacing in CSS and VVS Class IIa Indications 1. Recurrent syncope without clear, provocative events and with a hypersensitive cardioinhibitory response. 2. Significantly symptomatic and recurrent neurocardiogenic syncope associated with bradycardia documented spontaneously or at the time of tilt-table testing. NOTE: There are No Class IIb Indications. The Role of Pacing as Therapy for Vasovagal Syncope VVS with +HUT and cardioinhibitory response: Class IIa indication for pacing Three randomized, prospective trials reported benefits of pacing in select VVS patients: - VPS I 1 - VASIS 2 - SYDIT 3 Subsequent study results less clear - VPS II 4 - Synpace 5 - INVASY 6 2 Sutton R. Circulation. 2000;102: Ammirati F. Circ. 2001;104: Connolly SJ. J Am Coll Cardiol. 1999;33: Connolly S. JAMA. 2003;289: Giada F. PACE. 2003;26:1016 (abstract). 6 Occhetta E, et al. Europace. 2004;6:

31 Role of Pacing as Therapy for Vasovagal Syncope: Summary Three earlier studies single blind Bias? Pacemaker implantation may modulate reflex syncope and autonomic responses 1 Study results may differ based on pre-implant selection criteria and tilt-testing techniques Pacing therapy is effective in some but not all (cardioinhibition vs. vasodepression) In five pacing studies, syncope recurred in 33/156 (21%) of paced patients, 72/162 (44%) in non-paced patients (p<0.001) 2 1 Kapoor W. JAMA. 2003;289: Brignole M, et al.. Europace. 2004;6: Pacing for CSS and VVS Class III Indications 1. Hyperactive cardioinhibitory response to CS stimulation in absence of symptoms or in the presence of vague symptoms such as dizziness, lightheadedness, or both. 2. Recurrent syncope, lightheadedness or dizziness in absence of hyperactive cardioinhibitory response. 3. Situational vasovagal syncope in which avoidance behavior is effective.

32 Other Indications Other Indications 1. Pacing for AV Block Associated with Acute MI 2. Pacing after Cardiac Transplantation 3. Pacing in Children, Adolescents, and Patients with Congenital Heart Disease 4. Pacing for Hypertrophic Obstructive Cardiomyopathy 5. Pacing for Idiopathic Dilated Cardiomyopathy 6. Prevention and Termination of Tachyarrhythmias by Pacing 1. Pacemakers that Automatically Detect and Pace to Terminate Tachycardias 2. Pacing Recommendations to Prevent Tachycardia

33 Pacing for AV Block Associated with Acute Myocardial Infarction Class I Indications 1. Persistent second-degree AV block in the His- Purkinje system with bilateral BBB or third-degree AV block within or below the His-Purkinje system. 2. Transient, advanced (second- or third-degree) infranodal AV block and associated BBB. If the site of the block is uncertain, an EP study may be necessary. 3. Persistent and symptomatic second- or third-degree AV block. Pacing for AV Block Associated with Acute Myocardial Infarction Class IIa and IIb Indications Class IIa: None Class IIb: 1. Persistent second- or third-degree AV block at the AV node level.

34 Pacing for AV Block Associated with Acute Myocardial Infarction Class III Indications 1. Transient AV block in absence of intraventricular conduction defects. 2. Transient AV block in presence of isolated left anterior fascicular block (LAFB). 3. Acquired LAFB in absence of AV block. 4. Persistent first-degree AV block in presence of BBB that is old or age indeterminate. Pacing After Cardiac Transplantation Class I-III I III Indications Class I: 1. Symptomatic bradyarrhythmias/chronotropic incompetence not expected to resolve and other Class I indications for permanent pacing. Class IIa: None Class IIb: 1. Symptomatic bradyarrhythmias/chronotropic incompetence that, although transient, may persist for months and require intervention. Class III: 1. Postoperative asymptomatic bradyarrhythmias.

35 Pacing in Children, Adolescents, and Patients with Congenital Heart Disease Class I Indications 1. Advanced second- or third-degree AV block associated with symptomatic bradycardia, ventricular dysfunction or low cardiac output. 2. Sinus node dysfunction with correlation of symptoms during age-inappropriate bradycardia. 3. Postoperative advanced second- or third-degree AV block not expected to resolve, or persists >7 days after cardiac surgery. Pacing in Children, Adolescents, and Patients with Congenital Heart Disease Class I Indications 4. Congenital third-degree AV block with a wide QRS escape rhythm, complex ventricular ectopy, or ventricular dysfunction. 5. Congenital third-degree AV block in the infant with a ventricular rate <50-55 bpm or with congenital heart disease and a ventricular rate <70 bpm. 6. Sustained pause-dependent VT, with or without prolonged QT, in which the efficacy of pacing is thoroughly documented.

36 Pacing in Children, Adolescents, and Patients with Congenital Heart Disease Class IIa Indications 1. Brady-tachy syndrome with the need for chronic antiarrhythmic treatment other than digitalis. 2. Congenital third-degree AV block, beyond the first year of life, with an average heart rate <50 bpm, or abrupt pauses in the ventricular rate which are 2x or 3x the basic cycle length or associated with symptoms due to chronotropic incompetence. Pacing in Children, Adolescents, and Patients with Congenital Heart Disease Class IIa Indications 3. Long QT syndrome with 2:1 AV or third-degree AV block. 4. Asymptomatic sinus bradycardia in child with complex congenital heart disease where the resting heart rate is <40 bpm or >3 sec. pauses occur in the ventricular rate. 5. Patients with congenital heart disease and impaired hemodynamics due to sinus bradycardia or loss of AV synchrony.

37 Pacing in Children, Adolescents, and Patients with Congenital Heart Disease Class IIb Indications 1. Transient postoperative third-degree AV block that reverts to sinus rhythm with residual bifascicular block. 2. Congenital third-degree AV block in asymptomatic infant, child, adolescent or young adult with an acceptable rate, narrow QRS complex, and normal ventricular function. Pacing in Children, Adolescents, and Patients with Congenital Heart Disease Class IIb Indications 3. Asymptomatic sinus bradycardia in adolescents with congenital heart disease with resting heart rate <40 bpm or >3 second pauses in the ventricular rate. 4. Neuromuscular diseases with any degree of AV block (including first-degree AV block), with or without symptoms, because there may be unpredictable progression of AV conduction disease.

38 Pacing in Children, Adolescents, and Patients with Congenital Heart Disease Class III Indications 1. Transient postoperative AV block with return of normal AV conduction. 2. Asymptomatic postoperative bifascicular block with or without first-degree AV block. 3. Asymptomatic type I second-degree AV block. 4. Asymptomatic sinus bradycardia in adolescent where the longest RR interval is <3 sec and the minimum heart rate is >40 bpm. Pacing for Hypertrophic Obstructive Cardiomyopathy Class I, IIa and IIb Indications Class I: 1. Class I indications for sinus node dysfunction or AV block as previously described. Class IIa: None Class IIb: 1. Medically refractory, symptomatic hypertrophic cardiomyopathy with significant resting or provoked LV outflow obstruction..

39 Pacing for Hypertrophic Obstructive Cardiomyopathy Class III Indications 1. Patients who are asymptomatic or medically controlled. 2. Symptomatic patients without evidence of LV outflow obstruction. Pacing for Idiopathic Dilated Cardiomyopathy Class I, IIa and IIb Indications Class I: 1. Class I indications for sinus node dysfunction or AV block as previously described. Class IIa: 1. Biventricular pacing in medically refractory, symptomatic NYHA Class III/IV patients with idiopathic dilated or ischemic cardiomyopathy, prolonged QRS interval (>130 msec), LV enddiastolic diameter >55mm, and LVEF <35%. Class IIb: None

40 Pacing for Idiopathic Dilated Cardiomyopathy Class III Indications 1. Asymptomatic dilated cardiomyopathy. 2. Symptomatic dilated cardiomyopathy when patients are rendered asymptomatic by drug therapy. 3. Symptomatic ischemic cardiomyopathy when the ischemia is amenable to intervention.

Cardiac Implanted Electronic Devices Pacemakers, Defibrillators, Cardiac Resynchronization Devices, Loop Recorders, etc.

Cardiac Implanted Electronic Devices Pacemakers, Defibrillators, Cardiac Resynchronization Devices, Loop Recorders, etc. The Miracle of Living February 21, 2018 Matthew Ostrom MD,FACC,FHRS Division of