INDICATIONSFORPACINGDr.HOSSAMELMAHYCARDIOLOGYSPECIALTYREGISTRARROYALLANCASTERINFIRMARYH.ELMAHY20101INDICATIONSFORPACINGDr.HOSSAMEAimsofthetalkTypesofpermanentpacingbyindicationBradypacing-differentindicationsPacingafterAMIContraindicationsofpacingCRTICDsH.ELMAHY20102AimsofthetalkTypesofpermaThemostcommonindicationforbradypacingA:Bifascicular/trifascicularBlockB:AVblockC:SinusnodediseaseD:NeurallymediatedsyncopeE:PostAVNablationH.ELMAHY20103ThemostcommonindicationforFactorsthathelpdeterminetheneedforbradypacemakerinclude:A:Symptomssuchassyncope/presyncopeB:bradyarrhythmiaC:symptomscorrelatedtobradyarrhythmiaD:symptomsnotcorrelatedtoarrhythmiaE:noneoftheaboveH.ELMAHY20104FactorsthathelpdeterminethFollowingAMIPPMisindicatedinthepresenceofA:persistent2nddegreeTypeIIAVblockB:transient3rddegreeblockwithLBBBC:Persistent3rddegreeblockD:transient2nddegreeblockwithRBBBE:alloftheaboveH.ELMAHY20105FollowingAMIPPMisindicatedCRTisindicatedinpatientswithLVEF<35%iftheyalsohave:A:FunctionalclassNYHAIII-VIB:normalSR+wideQRS(>150msec)orwideQRS(120-149msec)withevidenceofmechanicaldyssynchronyonechoC:onoptimummedicaltherapyD:alloftheaboveE:noneoftheaboveH.ELMAHY20106CRTisindicatedinpatientswGUIDELINESACC/AHA/HRS2008PACINGGUIDELINESNICE2007CRTGUIDELINESNICE2006ICDGUIDELINESH.ELMAHY20107GUIDELINESACC/AHA/HRS2008ClassesofrecommendationinACC/AHAGuidelinesH.ELMAHY20108ClassesofrecommendationinATypesofPermanentPacingH.ELMAHY20109TypesofPermanentPacingH.ELMBRADYPACINGH.ELMAHY201010BRADYPACINGH.ELMAHY201010GeneralPrinciplesofBradypacingH.ELMAHY201011GeneralPrinciplesofBradypaDiseaseswithinAVNH.ELMAHY201012DiseaseswithinAVNH.ELMAHY20DiseasedistaltoAVNH.ELMAHY201013DiseasedistaltoAVNH.ELMAHY34yoldMale,presented2weeksafterreturnfromholidayinthelakedistrictwithmuscleandjointaches,headacheandsyncope!Onexaminationhehasskinlesion(image),rightVIIpalsyandaHRof30bpm.SerologyconfirmedLymediseaseH.ELMAHY20101434yoldMale,presented2weekPPMinAVBLOCKISNOTINDICATEDWhenexpectedtoresolveand/orunlikelytorecur(e.g.Lymediseaseordrugtoxicity)Asymptomatic1stdegreeAsymptomatictypeI2nddegreeH.ELMAHY201015PPMinAVBLOCKISNOTINDICAT65yoldmale,presentedwithacuteconfusion.ECGshowed3rddegreeHB.Telemetryrevealedseveralpauses.Thelongestpauseis4sec.Assumingallothercausesofacuteconfusionalstatehavebeenruledout,shouldhegetaPPM?H.ELMAHY20101665yoldmale,presentedwith76yoldfemale.KnownpermanentAFandHTN.ShehascometoseeyouinOPCandthistimecomplainsofepisodesoffeelinglightheaded.Sheiscurrentlyonwarfarin,amlodipine5mgOD,digoxin125mcgODandbisoprolol7.5mgOD.HerrestingHRis70-80bpmandBP130/75.Youarrangedaneventrecorderwhichrevealedperiodsofbradycardia(40bpm)concomitantwithhersymptoms.DoessheneedPPM?H.ELMAHY20101776yoldfemale.KnownpermaneACC/AHAClassIindicationsforpacingin3rd(andadvanced2nd)degreeAVBH.ELMAHY201018ACC/AHAClassIindicationsfPacinginchronicbi/trifascicularblockINDICATEDNOTINDICATEDIntermittent3rddegreeblockAdvancedtypeII2nddegreeblockAlternatingBBBFascicularblockwithoutAVblockorsymptomsFascicularblockwith1stdegreeAVblockwithoutsymptomsH.ELMAHY201019Pacinginchronicbi/trifascPPMafterAMI63yoldmalepresentedwithacuteinferiorMI.hewasthrombolysed.ThirtyminuteslaterhedevelopedVFarrest.CPRcommencedandonROSChewasinCHBwithescaperateof25bpm.HewaspacedtranscutaneouslyuntilaTPWwasinserted.2weekslaterhis12leadECGshowedSRwithLAHBbutnoevidenceofAVB.ShouldhegetaPPM?H.ELMAHY201020PPMafterAMI63yoldmaleprePPMafterAMITheneedforTPWafterAMIdoesn’tautomaticallyindicateaneedforPPMTransientconductiondisturbancesorLAHBarenotindicationsforPPMafterAMI.PPMisindicatedinthepresenceofadvancedAVB(2nd/3rddegree)whether(persistent)or(transientwithassociatedBBB)H.ELMAHY201021PPMafterAMITheneedforTPW60yoldmale,c/orecurrentpalpitationsandpresyncope.Hiscontinuousmonitorleadrecordingisshownbelow.DoesheneedPPM?H.ELMAHY20102260yoldmale,c/orecurrentpPacingSNDGenerallyPPMisindicatedwhensymptomaticbradycardiaispresentAlsoPPMindicatedwhensymptomaticbradycardiaiscausedbylong-termdrugforwhichthereisnoacceptedalternative.PPMisnotindicatedintheabsenceofsymptoms.H.ELMAHY201023PacingSNDGenerallyPPMisindPPMisindicatedinNeurallymediatedsyncopewhenthereis

recurrentsyncope+hypersensitivecardioinhibitoryresponsePPMisnotindicatedif:

1-hypersensitivecardioinhibitoryresponsewithoutsymptomsOR

2-SymptomswithouthypersensitivecardioinhibitoryresponseH.ELMAHY201024PPMisindicatedinNeurallymIssuedate:May2007Reviewdate:July2010NICEtechnologyappraisalguidance120CardiacresynchronizationtherapyforthetreatmentofheartfailureH.ELMAHY201025Issuedate:May2007NICEtechnCRT-PforHFH.ELMAHY201026CRT-PforHFH.ELMAHY201026CRT-DforHFH.ELMAHY201027CRT-DforHFH.ELMAHY201027Issuedate:January2006Reviewdate:July2007TechnologyAppraisal95ImplantablecardioverterdefibrillatorsforarrhythmiasReviewofTechnologyAppraisal11H.ELMAHY201028Issuedate:January2006TechnoICD-SecondarypreventionH.ELMAHY201029ICD-SecondarypreventionICD-PrimarypreventionH.ELMAHY201030ICD-PrimarypreventioTakehomemessage!Thereareonlytwoindicationsforpacing(excludingpacingforheartfailure):1-symptoms+slowHR2-highriskofsymptoms+slowHRdevelopinginthefutureH.ELMAHY201031Takehomemessage!ThereareonThemostcommonindicationforbradypacingA:Bifascicular/trifascicularBlockB:AVblockC:SinusnodediseaseD:NeurallymediatedsyncopeE:PostAVNablationH.ELMAHY201032ThemostcommonindicationforFactorsthathelpdeterminetheneedforbradypacemakerinclude:A:Symptomssuchassyncope/presyncopeB:bradyarrhythmiaC:symptomscorrelatedtobradyarrhythmiaD:symptomsnotcorrelatedtoarrhyt