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1、INDICATIONS FOR PACING,H.ELMAHY 2010,Dr. HOSSAM ELMAHY CARDIOLOGY SPECIALTY REGISTRAR ROYAL LANCASTER INFIRMARY,Aims of the talk,Types of permanent pacing by indication Brady pacing- different indications Pacing after AMI Contraindications of pacing CRT ICDs,H.ELMAHY 2010,The most common indication
2、for brady pacing,A: Bifascicular / trifascicular Block B: AV block C: Sinus node disease D:Neurally mediated syncope E: Post AVN ablation,H.ELMAHY 2010,Factors that help determine the need for brady pacemaker include:,A: Symptoms such as syncope / presyncope B: bradyarrhythmia C: symptoms correlated
3、 to bradyarrhythmia D: symptoms not correlated to arrhythmia E: none of the above,H.ELMAHY 2010,Following AMI PPM is indicated in the presence of,A: persistent 2nd degree Type II AV block B: transient 3rd degree block with LBBB C: Persistent 3rd degree block D: transient 2nd degree block with RBBB E
4、: all of the above,H.ELMAHY 2010,CRT is indicated in patients with LVEF 150 msec) or wide QRS (120-149 msec) with evidence of mechanical dyssynchrony on echo C: on optimum medical therapy D: all of the above E: none of the above,H.ELMAHY 2010,GUIDELINES,ACC /AHA / HRS 2008 PACING GUIDELINESNICE 2007
5、 CRT GUIDELINESNICE 2006 ICD GUIDELINES,H.ELMAHY 2010,Classes of recommendation in ACC / AHA Guidelines,H.ELMAHY 2010,Types of Permanent Pacing,H.ELMAHY 2010,BRADY PACING,H.ELMAHY 2010,General Principles of Brady pacing,H.ELMAHY 2010,Diseases within AVN,H.ELMAHY 2010,Disease distal to AVN,H.ELMAHY 2
6、010,34y old Male, presented 2 weeks after return from holiday in the lake district with muscle and joint aches, headache and syncope! On examination he has skin lesion (image), right VII palsy and a HR of 30 bpm. Serology confirmed Lyme disease,H.ELMAHY 2010,PPM in AV BLOCK IS NOT INDICATED,When exp
7、ected to resolve and / or unlikely to recur (e.g. Lyme disease or drug toxicity)Asymptomatic 1st degreeAsymptomatic type I 2nd degree,H.ELMAHY 2010,65 y old male, presented with acute confusion. ECG showed 3rd degree HB. Telemetry revealed several pauses. The longest pause is 4 sec. Assuming all oth
8、er causes of acute confusional state have been ruled out, should he get a PPM?,H.ELMAHY 2010,76 y old female. Known permanent AF and HTN. She has come to see you in OPC and this time complains of episodes of feeling lightheaded. She is currently on warfarin, amlodipine 5 mg OD, digoxin 125mcg OD and
9、 bisoprolol 7.5 mg OD. Her resting HR is 70-80 bpm and BP 130/75. You arranged an event recorder which revealed periods of bradycardia (40 bpm) concomitant with her symptoms. Does she need PPM?,H.ELMAHY 2010,ACC/ AHA Class I indications for pacing in 3rd (and advanced 2nd ) degree AVB,H.ELMAHY 2010,
10、Pacing in chronic bi / trifascicular block,INDICATED,NOT INDICATED,Intermittent 3rd degree blockAdvanced type II 2nd degree blockAlternating BBB,Fascicular block with out AV block or symptomsFascicular block with 1st degree AV block without symptoms,H.ELMAHY 2010,PPM after AMI,63 y old male presente
11、d with acute inferior MI. he was thrombolysed. Thirty minutes later he developed VF arrest. CPR commenced and on ROSC he was in CHB with escape rate of 25 bpm. He was paced transcutaneously until a TPW was inserted. 2 weeks later his 12 lead ECG showed SR with LAHB but no evidence of AVB. Should he
12、get a PPM?,H.ELMAHY 2010,PPM after AMI,The need for TPW after AMI doesnt automatically indicate a need for PPMTransient conduction disturbances or LAHB are not indications for PPM after AMI. PPM is indicated in the presence of advanced AVB (2nd / 3rd degree) whether (persistent) or (transient with a
13、ssociated BBB),H.ELMAHY 2010,60 y old male, c/o recurrent palpitations and presyncope. His continuous monitor lead recording is shown below. Does he need PPM?,H.ELMAHY 2010,Pacing SND,Generally PPM is indicated when symptomatic bradycardia is present Also PPM indicated when symptomatic bradycardia i
14、s caused by long-term drug for which there is no accepted alternative. PPM is not indicated in the absence of symptoms.,H.ELMAHY 2010,PPM is indicated in Neurally mediated syncope when there is recurrent syncope + hypersensitive cardio inhibitory response,H.ELMAHY 2010,PPM is not indicated if : 1- h
15、ypersensitive cardio inhibitory response without symptoms OR 2- Symptoms without hypersensitive cardio inhibitory response,H.ELMAHY 2010,CRT-P for HF,H.ELMAHY 2010,CRT-D for HF,H.ELMAHY 2010,H.ELMAHY 2010,ICD- Secondary prevention,H.ELMAHY 2010,ICD- Primary prevention,H.ELMAHY 2010,Take home message
16、!,There are only two indications for pacing (excluding pacing for heart failure):1- symptoms + slow HR2- high risk of symptoms + slow HR developing in the future,H.ELMAHY 2010,The most common indication for brady pacing,A: Bifascicular / trifascicular Block B: AV block C: Sinus node disease D:Neurally mediated syncope E: Post AVN ablation,H.ELMAHY 2010,Factors that help determine the need for brady pacemaker include:,
