Pacing and CRT

Question 1

ILRs

Answer 1

• In patients with infrequent syncope (<1 / month)

Question 2

Sinus node disease management

Answer 2

• Indicated for SND with symptoms
• Programme PPM to minimise V pacing in SND
• Can use PPM for tachy-brady variant of SND in order to facilitate pharmacological treatment of tachycardia unless ablation preferred
• Consider PPM if sinus pauses >6 seconds with no symptoms

Question 3

AV block - management

Answer 3

• PPM indicated for patients in SR with 3rd degree AV block, type 2 second degree block, infra-nodal 2:1 block or high degree AV block regardless of symptoms
• PPM indicated in AF and 3rd degree or high degree AV block
• Permanent AF with AV block - VVIR pacing
• Consider PPM for type 1 2nd degree AV block with symptoms, particularly if intra or infra-hisian on EPS
• Consider PPM for patients with severe symptoms attributable to 1st degree AV block (PR >300ms)

Question 4

Bundle branch block - management

Answer 4

• Bifascicular block and unexplained syncope - PPM if His-ventricualr interval >70ms on EPS, or 2nd or 3rd degree intra or infra Hisian block during incremental atrial pacing
• Pacing is indicated in alterating BBB with or without symptoms

Question 5

Pacing in reflex syncope

Answer 5

• Recurrent, spontaneous, unpredictable syncope in age >40 indicated in:
• 3s pause with symptoms
• 6s pause without symptoms
• Cardioinhibitory carotid sinus syndrome
• Asystolic tilt test

Question 6

CRT indication

Answer 6

• Indicated symptomatic patients in sinus rhythm, HF, LVEF ≤35%, QRSd ≥150ms, LBBB morpholgy, despite OMT (1a)
• Consider in above but QRSd 130-149 (IIa)
• Consider in top scenario but non LBBB morphology
• May consider in top scenario but non LBBB morphology and QRSd 130-149
• CRT not indicated when QRSd <130 unless indication for RV pacing
• If LVEF ≤40% and has pacing indication for AV block, CRT rather than RV pacing - includes AF patients

Question 7

Pacing Post MI and heart surgery

Answer 7

• Pacing indicated post MI with same indications as general population after 5 day waiting period
• Pacing indicated post cardiac surgery for high degree or complete AV block after waiting period of at least 5 days
• Wait for 6 weeks post surgery before PPM for SND
• Consider immediate epicardial PPM implantation if complete or high degree AV block post endocarditis surgery
• Avoid transvalvular leads in patients post mechanical TVR who need pacing

Question 8

Predictors of pacing in TAVI

Answer 8

Question 9

Management of conduction disturbance post TAVI

Answer 9