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Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,H.ELMAHY 2010,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,H.ELMAHY 2010,*,INDICATIONSFORPACING,Dr.HOSSAMELMAHY,CARDIOLOGYSPECIALTYREGISTRAR,ROYALLANCASTERINFIRMARY,H.ELMAHY2010,1,Aims of the talk,Types of permanent pacing by indication,Brady pacing- different indications,Pacing after AMI,Contraindications of pacing,CRT,ICDs,H.ELMAHY 2010,2,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 2010,3,Factors that help determine the need for brady pacemaker include:,A: Symptoms such as syncope / presyncope,B: bradyarrhythmia,C: symptoms correlated to bradyarrhythmia,D: symptoms not correlated to arrhythmia,E: none of the above,H.ELMAHY 2010,4,Following AMI PPM is indicated in the presence of,A: persistent 2,nd,degree Type II AV block,B: transient 3,rd,degree block with LBBB,C: Persistent 3,rd,degree block,D: transient 2,nd,degree block with RBBB,E: all of the above,H.ELMAHY 2010,5,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 2010,6,GUIDELINES,ACC /AHA / HRS 2008 PACING GUIDELINES,NICE 2007 CRT GUIDELINES,NICE 2006 ICD GUIDELINES,H.ELMAHY 2010,7,Classes of recommendation in ACC / AHA Guidelines,H.ELMAHY 2010,8,Types of Permanent Pacing,H.ELMAHY 2010,9,BRADY PACING,H.ELMAHY 2010,10,General Principles of Brady pacing,H.ELMAHY 2010,11,Diseases within AVN,H.ELMAHY 2010,12,Disease distal to AVN,H.ELMAHY 2010,13,34y 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 2010,14,PPM in AV BLOCK IS,NOT INDICATED,When expected to resolve and / or unlikely to recur (e.g. Lyme disease or drug toxicity),Asymptomatic 1,st,degree,Asymptomatic type I 2,nd,degree,H.ELMAHY 2010,15,65 y old male, presented with acute confusion. ECG showed 3,rd,degree HB. Telemetry revealed several pauses. The longest pause is 4 sec. Assuming all other causes of acute confusional state have been ruled out, should he get a PPM?,H.ELMAHY 2010,16,76 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 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 2010,17,ACC/ AHA Class I indications for pacing in 3,rd,(and advanced 2,nd,) degree AVB,H.ELMAHY 2010,18,Pacing in chronic bi / trifascicular block,INDICATED,NOT INDICATED,Intermittent 3,rd,degree block,Advanced type II 2,nd,degree block,Alternating BBB,Fascicular block with out AV block or symptoms,Fascicular block with 1,st,degree AV block without symptoms,H.ELMAHY 2010,19,PPM after AMI,63 y old male presented 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 get a PPM?,H.ELMAHY 2010,20,PPM after AMI,The need for TPW after AMI doesnt automatically indicate a need for PPM,Transient conduction disturbances or LAHB are not indications for PPM after AMI.,PPM is indicated in the presence of advanced AVB (2,nd,/ 3,rd,degree) whether (persistent) or (transient with associated BBB),H.ELMAHY 2010,21,60 y old male, c/o recurrent palpitations and presyncope. His continuous monitor lead recording is shown below. Does he need PPM?,H.ELMAHY 2010,22,Pacing SND,Generally PPM is indicated when symptomatic bradycardia is present,Also PPM indicated when symptomatic bradycardia is caused by long-term drug for which there is no accepted alternative.,PPM is not indicated in the absence of symptoms.,H.ELMAHY 2010,23,PPM is indicated in Neurally mediated syncope,when there isrecurrent syncope + hypersensitive cardio inhibitory response,PPM is not indicated,if :1- hypersensitive cardio inhibitory response without symptoms,OR2- Symptoms without hypersensitive cardio inhibitory response,H.ELMAHY 2010,24,Issue date:,May 2007,Review date:,July 2010,NICE technology appraisal guidance 120,Cardiac resynchronization therapy for the treatment of heart failure,H.ELMAHY 2010,25,CRT-P for HF,H.ELMAHY 2010,26,CRT-D for HF,H.ELMAHY 2010,27,Issue date:,January 2006,Review date:,July 2007,Technology Appraisal 95,Implantable cardioverter defibrillators for arrhythmias,Review of Technology Appraisal 11,H.ELMAHY 2010,28,ICD- Secondary prevention,H.ELMAHY 2010,29,ICD- Primary prevention,H.ELMAHY 2010,30,Take home message!,There are only two indications for pacing (excluding pacing for heart failure):,1- symptoms + slow HR,2- high risk of symptoms + slow HR developing in the future,H.ELMAHY 2010,31,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 2010,32,Factors that help determine the need for brady pacemaker include:,A: Symptoms such as syncope / presyncope,B: bradyarrhythmia,C: symptoms correlated to bradyarrhythmia,D: symptoms not correlated to arrhythmia,E: none of the above,H.ELMAHY 2010,33,Following AMI PPM is indicated in the presence of,A: persistent 2,nd,degree Type II AV block,B: transient 3,rd,degree block with LBBB,C: Persistent 3,rd,degree block,D: transient 2,nd,degree block with RBBB,E: all of the above,H.ELMAHY 2010,34,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 2010,35,THANK YOU,H.ELMAHY 2010,36,
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