Cardiac Pacing Indications

Question 1

Cardiac pacing in TAVR

Answer 1

○Persistent high degree AVB Class I
○New onset alternating BBB Class I
○Pre existing RBB w/ new post procedure conduction disturbance Class IIa (transient high degree AVB block, PR prolongation, axis change)

Question 2

Pre­dic­tors for per­ma­nent pac­ing af­ter tran­scatheter aor­tic valve im­plan­ta­tion

Answer 2

○ ECG :
Right BBB
PR-​in­ter­val pro­lon­ga­tion
Left an­te­ri­or hemi­block

○Pa­tient :
Old­er age (per 1-​year in­crease)
Male sex
Larg­er body mass in­dex (per 1-​unit in­crease)

○Anatom­i­cal
Se­vere mi­tral an­nu­lar cal­ci­fi­ca­tion
LV out­flow tract cal­ci­fi­ca­tions
Mem­bra­nous sep­tum length
Porce­lain aor­ta
High­er mean aor­tic valve gra­di­ent

○ Pro­ce­du­ral
Self-​ex­pand­able valve
Deep­er valve im­plan­ta­tion
Larg­er ra­tio be­tween pros­the­sis di­am­e­ter ver­sus an­nu­lus or LV out­flow tract di­am­e­ter
Bal­loon post-​di­lata­tion
TAVI in native valve vs. valve in valve procedure

Question 3

Leadless pacemaker indications

Answer 3

○No up­per ex­trem­i­ty ve­nous ac­cess ex­ists

○Risk of de­vice pock­et in­fec­tion is par­tic­u­lar­ly high such as pre­vi­ous in­fec­tion and pa­tients on haemodial­y­sis.

Question 4

Car­diac pac­ing af­ter car­diac surgery and heart trans­plan­ta­tion

Answer 4

1) High-​de­gree or com­plete AVB af­ter car­diac surgery
A pe­ri­od of clin­i­cal ob­ser­va­tion of at least 5 days is in­di­cat­ed to as­sess whether the rhythm dis­tur­bance is tran­sient and re­solves.
How­ev­er, in the case of com­plete AVB with low or no es­cape rhythm when res­o­lu­tion is un­like­ly, this ob­ser­va­tion pe­ri­od can be short­ened. Class I

2) Surgery for valvu­lar en­do­cardi­tis and in­tra­op­er­a­tive com­plete AVB
Im­me­di­ate epi­car­dial pace­mak­er im­plan­ta­tion should be con­sid­ered in pa­tients with surgery for valvu­lar en­do­cardi­tis and com­plete AVB if one of the fol­low­ing pre­dic­tors of per­sis­tence is pre­sent : pre­op­er­a­tive con­duc­tion ab­nor­mal­i­ty, Staphy­lo­coc­cus au­reus in­fec­tion, in­trac­ar­diac ab­scess, tri­cus­pid valve in­volve­ment, or pre­vi­ous valvu­lar surgery.

3) SND af­ter car­diac surgery and heart trans­plan­ta­tion
Be­fore per­ma­nent pace­mak­er im­plan­ta­tion, a pe­ri­od of ob­ser­va­tion of up to 6 weeks should be con­sid­ered.

4) Chronotrop­ic in­com­pe­tence af­ter heart trans­plan­ta­tion
Car­diac pac­ing should be con­sid­ered for chronotrop­ic in­com­pe­tence per­sist­ing for more than 6 weeks af­ter heart trans­plan­ta­tion to im­prove qual­i­ty of life.

5) Pa­tients re­quir­ing pac­ing at the time of tri­cus­pid valve surgery
Transvalvu­lar leads should be avoid­ed and epi­car­dial ven­tric­u­lar leads used. Dur­ing tri­cus­pid valve surgery, re­moval of pre-​ex­ist­ing transvalvu­lar leads should be con­sid­ered and pre­ferred over sewing-​in the lead be­tween the an­nu­lus and a bio­pros­the­sis or an­nu­lo­plas­ty ring. In the case of an iso­lat­ed tri­cus­pid an­nu­lo­plas­ty based on an in­di­vid­u­al risk−ben­e­fit anal­y­sis, a pre-​ex­ist­ing RV lead may be left in place with­out jail­ing it be­tween ring and an­nu­lus.

6) Pa­tients re­quir­ing pac­ing af­ter bi­o­log­i­cal tri­cus­pid valve re­place­ment/​tri­cus­pid valve ring re­pair
When ven­tric­u­lar pac­ing is in­di­cat­ed, transve­nous im­plan­ta­tion of a coro­nary si­nus lead or min­i­mal­ly in­va­sive place­ment of an epi­car­dial ven­tric­u­lar lead should be con­sid­ered and pre­ferred over a transve­nous transvalvu­lar ap­proach.
All of these are Class 2a

Question 5

Pacemaker after MI ?

Answer 5

when AVB does not re­solve with­in a wait­ing pe­ri­od of at least 5 days af­ter MI.

Question 6

Pacemakers in congenital heart disease :

Answer 6

In pa­tients with con­gen­i­tal com­plete or high de­gree AVB, pac­ing is rec­om­mend­ed if one of the fol­low­ing risk fac­tors is pre­sent:

a) Symp­toms

b) Paus­es >3x the cy­cle length of the ven­tric­u­lar es­cape rhythm

c) Broad QRS es­cape rhythm

d) Pro­longed QT in­ter­val

e) Com­plex ven­tric­u­lar ec­topy

f) Mean day­time heart rate <50 b.p.m.

Question 7

Management of anticoagulation in pacemaker procedures

Answer 7

VKA : continue
NOAC : continue or interrrupt as per operator preference
OAC + antiplatelet : continue OAC + discontinue antiplatelet

Question 8

Management of antiplatelt therapy in pacemaker procedures

Answer 8

Procedural bleeding risk :
1. Low : 1st implant
2. High : device exchange, revision, upgrade

Thrombotic risk :
A. Low : > 1month post PCI or > 6 months post ACS
B. High : < 1month post PCI or < 6 months post ACS

If A : continue aspirin + discontinue clopidogrel at least 5 days

If B+1 : postpone otherwise continue both antiplatelet

If B+2 : continue aspirin + discontinue clopidogrel at least 5 days + bridging with anti GP IIb/IIIa

Question 9

De­ci­sion al­go­rithm for pa­tients with un­ex­plained syn­cope and bun­dle branch block

Answer 9

Bifascicular block
If LVEF < 35% : ICD/CRT-D
If LVEF > 35% :
If elderly + frail : pacemaker
Otherwise : EP study / carotid sinus massage / ILR and adapted therapy

Question 10

In­di­ca­tions for pac­ing in reflex syncope

Answer 10

Pac­ing is rec­om­mend­ed in high­ly se­lect­ed pa­tients with re­flex syn­cope (i.e. those >40 years of age with se­vere re­cur­rent un­pre­dictable syn­co­pal episodes when asys­tole has been doc­u­ment­ed, ei­ther in­duced by CSM, tilt test­ing, or record­ed through a mon­i­tor­ing sys­tem).

Car­dioin­hibito­ry carotid si­nus syn­drome is de­fined when the spon­ta­neous syn­cope is re­pro­duced by the carotid si­nus mas­sage in the pres­ence of an asys­tolic pause >3 s;

Asys­tolic tilt pos­i­tive test is de­fined when the spon­ta­neous syn­cope is re­pro­duced in the pres­ence of an asys­tolic pause >3 s.

A symp­tomat­ic asys­tolic pause(s) >3 s or asymp­tomat­ic pause(s) >6 s due to si­nus ar­rest, atri­oven­tric­u­lar block, or the com­bi­na­tion of the two sim­i­lar­ly de­fine asys­tole de­tect­ed by im­plantable loop recorder.

Question 11

Car­diac resyn­chro­niza­tion ther­a­py in pa­tients in si­nus rhythm

Answer 11

CRT is rec­om­mend­ed for symp­tomat­ic pa­tients NYHA II-IV with HF in SR with LVEF ≤35%, QRS du­ra­tion ≥150 ms, and LBBB QRS mor­phol­o­gy de­spite OMT, in or­der to im­prove symp­toms and re­duce mor­bid­i­ty and mor­tal­i­ty. Class I

Question 12

Indications for CRT in patients w/ Afib :

Answer 12

◇ In pa­tients with HF with per­ma­nent AF who are can­di­dates for CRT :

1A) CRT should be con­sid­ered for pa­tients with HF and LVEF ≤35% in NYHA class III or IV de­spite OMT if they are in AF and have in­trin­sic QRS ≥130 ms, pro­vid­ed a strat­e­gy to en­sure biven­tric­u­lar cap­ture is in place, in or­der to im­prove symp­toms and re­duce mor­bid­i­ty and mor­tal­i­ty.

◇ In pa­tients with symp­tomat­ic AF and an un­con­trolled heart rate who are can­di­dates for AVJ ab­la­tion (ir­re­spec­tive of QRS du­ra­tion) :

2A) CRT is rec­om­mend­ed in pa­tients with HFrEF. I

2B) CRT rather than stan­dard RV pac­ing should be con­sid­ered in pa­tients with HFm­rEF. IIa

2C) RV pac­ing should be con­sid­ered in pa­tients with HF­pEF. IIa

1B) AVJ ab­la­tion should be added in case of in­com­plete biven­tric­u­lar pac­ing (<90–95%) due to con­duct­ed AF.

◇

Question 13

Rec­om­men­da­tion for pa­tients with heart fail­ure and atri­oven­tric­u­lar block

Answer 13

CRT rather than RV pac­ing is rec­om­mend­ed for pa­tients with HFrEF (<40%) re­gard­less of NYHA class who have an in­di­ca­tion for ven­tric­u­lar pac­ing and high de­gree AVB in or­der to re­duce mor­bid­i­ty. This in­cludes pa­tients with AF. Class I