Third degree AV block surgery: Difference between revisions

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{{Third degree AV block}}
{{Third degree AV block}}
{{CMG}}; {{AE}} {{CZ}}; {{RT}} {{Soroush}} [[User:Qasim Khurshid|Qasim Khurshid, M.B.B.S]] [5]
{{CMG}}; {{AE}} {{Sara.Zand}} {{CZ}}; {{RT}} {{Soroush}} [[User:Qasim Khurshid|Qasim Khurshid, M.B.B.S]] [5]


==Overview==
==Overview==
Cardiac [[Pacemaker|pacemakers]] are effective treatments for a variety of cardiac conduction abnormalities and can reestablish adequate [[circulation]] by generating appropriate heart rate and cardiac response. Two main factors guide the majority of decisions regarding [[permanent pacemaker]] insertion. First is the association of symptoms with [[Cardiac arrhythmia|arrhythmia]], and second is the potential for progression of the rhythm disturbance.
Cardiac [[Pacemaker|pacemakers]] are effective treatments for a variety of [[cardiac]] conduction abnormalities and can reestablish adequate [[circulation]] by generating appropriate [[heart rate]] and [[cardiac]] response. Two main factors guide the majority of decisions regarding [[permanent pacemaker]] insertion. First is the association of [[symptoms]] with [[Cardiac arrhythmia|arrhythmia]], and second is the potential for progression of the [[rhythm]] disturbance. [[Symptoms]] related to [[atrioventricular block]] are determining factor of placing [[permanent pacemaker]], regardless of the level of [[atrioventricular block]]. [[Permanent pacemaker]] is warranted if the site of [[atrioventricular]] block is Infranodal, regardless of the presence or absence of [[symptoms]]. [[Temporary transvenous pacing]] is used to provide [[hemodynamic]] support or back-up pacing to prevent [[asystole]]. If [[atrioventricular]] block seems to be irreversible, it is better to proceed directly with [[permanent pacemaker]] implantation.
 
== Surgery ==
*A [[permanent pacemaker]] insertion is a minimally invasive procedure.
::* The procedure is typically performed in a cardiac catheterization lab or an operating room.
::* [[Transvenous]] access to the [[heart]] chambers under local [[anesthesia]] is the preferred technique, most commonly via the [[Subclavian veins|subclavian vein]], the [[cephalic vein]], or the [[internal jugular vein]] or the [[femoral vein]].
::*The pacing generator is most commonly placed subcutaneously in the pre-[[pectoral]] region.
::* [[Placement]] of [[pacemaker leads]], surgically via [[thoracotomy]], is rarely used these days.
*Factors associated implantation of [[permanent pacemaker]] that should be noticed include:
::* Symptoms related to [[bradycardia]] ( major determinant)
::*Site of [[atrioventricular block]] including infranodal [[atrioventricular block]] and risk of progression to [[complete heart block]] due to unstable [[ventricular]] scape [[rhythm]]
::* Side effects of high burden of [[right ventricular]] [[pacing]]
::*Concomitant [[systemic]] disease as a potential risk of [[atrioventricular block]] or [[ventricular arrhythmia]]
 
==Recommendation for implantation of temporary pacing for [[bradycardia]] associated [[atrioventricular block]]==
<ref name="KusumotoSchoenfeld2019">{{cite journal|last1=Kusumoto|first1=Fred M.|last2=Schoenfeld|first2=Mark H.|last3=Barrett|first3=Coletta|last4=Edgerton|first4=James R.|last5=Ellenbogen|first5=Kenneth A.|last6=Gold|first6=Michael R.|last7=Goldschlager|first7=Nora F.|last8=Hamilton|first8=Robert M.|last9=Joglar|first9=José A.|last10=Kim|first10=Robert J.|last11=Lee|first11=Richard|last12=Marine|first12=Joseph E.|last13=McLeod|first13=Christopher J.|last14=Oken|first14=Keith R.|last15=Patton|first15=Kristen K.|last16=Pellegrini|first16=Cara N.|last17=Selzman|first17=Kimberly A.|last18=Thompson|first18=Annemarie|last19=Varosy|first19=Paul D.|title=2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society|journal=Circulation|volume=140|issue=8|year=2019|issn=0009-7322|doi=10.1161/CIR.0000000000000628}}</ref>




==Surgury==
 
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
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| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for temporary pacing for bradycardia associated atrioventricular block'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Medical therapy  ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[symptomatic]] [[bradycardia]]  associated second or [[third degree atrioventricular block]], refractory to [[medications]], [[ temporary transvenous pacing]] is recommended to increase [[heart rate]] and improve [[symptoms]]<br>
 
|}
===Comment===
 
* [[Temporary transvenous pacing]] is used to provide [[hemodynamic]] support or back-up pacing to prevent [[asystole]].
* If [[atrioventricular]] block seems to be irreversible, it is better to proceed directly with [[permanent pacemaker]] implantation.
* When [[transvenous]] pacing wires left in place for a longer duration (>48 hours), the likelihood of complications increases.<ref name="pmid8620131">{{cite journal |vauthors=Murphy JJ |title=Current practice and complications of temporary transvenous cardiac pacing |journal=BMJ |volume=312 |issue=7039 |pages=1134 |date=May 1996 |pmid=8620131 |pmc=2350635 |doi=10.1136/bmj.312.7039.1134 |url=}}</ref>
* Transcutaneous pacing is used as a short-term bridge to temporary or permanent transvenous pacing or the resolution of [[bradycardia]].
* There is no survival benefit to hospital discharge when transcutaneous pacing is used in the prehospital phase of [[bradyasystolic]] [[cardiac arrest]]. <ref name="pmid17933452">{{cite journal |vauthors=Morrison LJ, Long J, Vermeulen M, Schwartz B, Sawadsky B, Frank J, Cameron B, Burgess R, Shield J, Bagley P, Mausz V, Brewer JE, Dorian P |title=A randomized controlled feasibility trial comparing safety and effectiveness of prehospital pacing versus conventional treatment: 'PrePACE' |journal=Resuscitation |volume=76 |issue=3 |pages=341–9 |date=March 2008 |pmid=17933452 |pmc=7126680 |doi=10.1016/j.resuscitation.2007.08.008 |url=}}</ref>
* Due to high capture thresholds and [[patient]] [[discomfort]], [[transcutaneous pacing]] is poorly tolerated for prolonged use.
 
==Recommendation for placement of [[permanent pacing]] ==
==Recommendation for placement of [[permanent pacing]] ==
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
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{|
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! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2018 AHA/ACC/HRS Guideline
! colspan="2" style="background: PapayaWhip;" align="center" + |The above table adopted from 2018 AHA/ACC/HRS Guideline<ref name="KusumotoSchoenfeld2019">{{cite journal|last1=Kusumoto|first1=Fred M.|last2=Schoenfeld|first2=Mark H.|last3=Barrett|first3=Coletta|last4=Edgerton|first4=James R.|last5=Ellenbogen|first5=Kenneth A.|last6=Gold|first6=Michael R.|last7=Goldschlager|first7=Nora F.|last8=Hamilton|first8=Robert M.|last9=Joglar|first9=José A.|last10=Kim|first10=Robert J.|last11=Lee|first11=Richard|last12=Marine|first12=Joseph E.|last13=McLeod|first13=Christopher J.|last14=Oken|first14=Keith R.|last15=Patton|first15=Kristen K.|last16=Pellegrini|first16=Cara N.|last17=Selzman|first17=Kimberly A.|last18=Thompson|first18=Annemarie|last19=Varosy|first19=Paul D.|title=2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society|journal=Circulation|volume=140|issue=8|year=2019|issn=0009-7322|doi=10.1161/CIR.0000000000000628}}</ref>
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===Notes===
* [[Symptoms]] related to [[atrioventricular block]] are determining factor of placing [[permanent pacemaker]], regardless of the level of [[atrioventricular block]].
* [[Permanent pacemaker]] is warranted if the site of [[atrioventricular]] block is Infranodal, regardless of the presence or absence of [[symptoms]].<ref name="pmid4005079">{{cite journal |vauthors=Shaw DB, Kekwick CA, Veale D, Gowers J, Whistance T |title=Survival in second degree atrioventricular block |journal=Br Heart J |volume=53 |issue=6 |pages=587–93 |date=June 1985 |pmid=4005079 |pmc=481819 |doi=10.1136/hrt.53.6.587 |url=}}</ref>
* Varied degree of [[atrioventricular block]] from first degree [[atrioventricular block]] to complete [[atrioventricular block]]  may develope over the time in [[neuromuscular disorders]] such as [[muscular dystrophies]] or [[Kearns-Sayre syndrome]].<ref name="pmid24775453">{{cite journal |vauthors=Facenda-Lorenzo M, Hernández-Afonso J, Rodríguez-Esteban M, de León-Hernández JC, Grillo-Pérez JJ |title=Cardiac manifestations in myotonic dystrophy type 1 patients followed using a standard protocol in a specialized unit |journal=Rev Esp Cardiol (Engl Ed) |volume=66 |issue=3 |pages=193–7 |date=March 2013 |pmid=24775453 |doi=10.1016/j.rec.2012.08.011 |url=}}</ref>
* Intermittent [[second-degree]] or [[third-degree atrioventricular block]] on 24-hour [[ambulatory electrocardiographic monitoring]] or [[atrioventricular block]] on resting [[ECG]] was found in 20% of [[patients]] with [[myotonic dystrophy]] type 1.
* In the presence of [[atrial fibrillation]] and slow regular [[ventricular]] response and wide [[QRS]]  and pauses >3 seconds, infranodal [[atrioventricular block]] may be suspected. <ref name="pmid4817704">{{cite journal |vauthors=Dhingra RC, Denes P, Wu D, Chuquimia R, Rosen KM |title=The significance of second degree atrioventricular block and bundle branch block. Observations regarding site and type of block |journal=Circulation |volume=49 |issue=4 |pages=638–46 |date=April 1974 |pmid=4817704 |doi=10.1161/01.cir.49.4.638 |url=}}</ref>
* [[Atrioventricular block]] may develop by using [[betablocker]] for [[MI]] or [[heartfailure]] and [[amiodarone]] and [[sotalol]] for [[atrial fibrillation]] [[patients]].
* The benefit of using these [[medications]] should be balanced over the side effects of [[right ventricular pacing]].<ref name="pmid10938495">{{cite journal |vauthors=Dargie HJ |title=Design and methodology of the CAPRICORN trial - a randomised double blind placebo controlled study of the impact of carvedilol on morbidity and mortality in patients with left ventricular dysfunction after myocardial infarction |journal=Eur J Heart Fail |volume=2 |issue=3 |pages=325–32 |date=September 2000 |pmid=10938495 |doi=10.1016/s1388-9842(00)00098-2 |url=}}</ref>
* [[Atrioventricular block]] in the setting of [[cardiac sarcoidosis]] may resolve by using [[corticosteroids]] for 30 days.<ref name="pmid27614001">{{cite journal |vauthors=Zhou Y, Lower EE, Li HP, Costea A, Attari M, Baughman RP |title=Cardiac Sarcoidosis: The Impact of Age and Implanted Devices on Survival |journal=Chest |volume=151 |issue=1 |pages=139–148 |date=January 2017 |pmid=27614001 |doi=10.1016/j.chest.2016.08.1457 |url=}}</ref>
* Evidence of  prolonged HV interval (>55 ms) despite a narrow [[QRS]] was found in AL [[cardiac]] [[amyloidosis]].
* [[Mutations]] in the lamin A/C gene can present with [[atrioventricular block]], [[atrial arrhythmias]], and [[ventricular arrhythmia]].<ref name="pmid23183350">{{cite journal |vauthors=van Rijsingen IA, Nannenberg EA, Arbustini E, Elliott PM, Mogensen J, Hermans-van Ast JF, van der Kooi AJ, van Tintelen JP, van den Berg MP, Grasso M, Serio A, Jenkins S, Rowland C, Richard P, Wilde AA, Perrot A, Pankuweit S, Zwinderman AH, Charron P, Christiaans I, Pinto YM |title=Gender-specific differences in major cardiac events and mortality in lamin A/C mutation carriers |journal=Eur J Heart Fail |volume=15 |issue=4 |pages=376–84 |date=April 2013 |pmid=23183350 |doi=10.1093/eurjhf/hfs191 |url=}}</ref>
* Risk of  [[atrioventricular block]] and [[sudden cardiac death]] may increase in the setting of [[lamin A/C mutation]].
* In one study, the risk of  [[ventricular arrhythmias]] increased in the presence of first-degree [[atrioventricular block]] in [[lamin A/C mutation]].<ref name="pmid24058181">{{cite journal |vauthors=Hasselberg NE, Edvardsen T, Petri H, Berge KE, Leren TP, Bundgaard H, Haugaa KH |title=Risk prediction of ventricular arrhythmias and myocardial function in Lamin A/C mutation positive subjects |journal=Europace |volume=16 |issue=4 |pages=563–71 |date=April 2014 |pmid=24058181 |doi=10.1093/europace/eut291 |url=}}</ref>
*[[Pseudo-pacemaker syndrome]] may develop in the setting of severe [[first-degree atrioventricular block]] with  very long PR interval , [[atrial contraction ]] during the closed [[atrioventricular valves]] leading to an increase in [[wedge pressure]] and a decrease in [[cardiac output]].<ref name="pmid29707483">{{cite journal |vauthors=Lader JM, Park D, Aizer A, Holmes D, Chinitz LA, Barbhaiya CR |title=Slow pathway modification for treatment of pseudo-pacemaker syndrome due to first-degree atrioventricular block with dual atrioventricular nodal physiology |journal=HeartRhythm Case Rep |volume=4 |issue=3 |pages=98–101 |date=March 2018 |pmid=29707483 |pmc=5919070 |doi=10.1016/j.hrcr.2017.10.003 |url=}}</ref>




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{{Family tree | | | | | | | | | |A19| | | | |A19=[[His bundle pacing ]] (class2b)}}
{{Family tree | | | | | | | | | |A19| | | | |A19=[[His bundle pacing ]] (class2b)}}
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{|
{|
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2018 AHA/ACC/HRS Guideline
! colspan="2" style="background: PapayaWhip;" align="center" + |The above algorithm adopted from 2018 AHA/ACC/HRS Guideline<ref name="KusumotoSchoenfeld2019">{{cite journal|last1=Kusumoto|first1=Fred M.|last2=Schoenfeld|first2=Mark H.|last3=Barrett|first3=Coletta|last4=Edgerton|first4=James R.|last5=Ellenbogen|first5=Kenneth A.|last6=Gold|first6=Michael R.|last7=Goldschlager|first7=Nora F.|last8=Hamilton|first8=Robert M.|last9=Joglar|first9=José A.|last10=Kim|first10=Robert J.|last11=Lee|first11=Richard|last12=Marine|first12=Joseph E.|last13=McLeod|first13=Christopher J.|last14=Oken|first14=Keith R.|last15=Patton|first15=Kristen K.|last16=Pellegrini|first16=Cara N.|last17=Selzman|first17=Kimberly A.|last18=Thompson|first18=Annemarie|last19=Varosy|first19=Paul D.|title=2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society|journal=Circulation|volume=140|issue=8|year=2019|issn=0009-7322|doi=10.1161/CIR.0000000000000628}}</ref>
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===Methods of implantation [[permanent pacing]]===
 
* Common side effects of [[right ventricular]] pacing include [[ventricular dysfunction ]] or [[heart failure]] [[symptoms]].
 
* Lower baseline [[LVEF]] and a higher percentage of [[RV]] pacing may predict [[RV ]] pacing [[cardiomyopathy]].<ref name="pmid15106214">{{cite journal |vauthors=Dretzke J, Toff WD, Lip GY, Raftery J, Fry-Smith A, Taylor R |title=Dual chamber versus single chamber ventricular pacemakers for sick sinus syndrome and atrioventricular block |journal=Cochrane Database Syst Rev |volume= |issue=2 |pages=CD003710 |date=2004 |pmid=15106214 |pmc=8095057 |doi=10.1002/14651858.CD003710.pub2 |url=}}</ref>
 
* Risk of [[RV]] pacing-induced [[cardiomyopathy]] increases when [[ RV]] pacing exceeds 40% or perhaps as low as 20%.
 
* [[CRT]]-P reduced  [[left ventricular ]] [[end-systolic]] volume and improved [[LVEF]] in comparison with [[RV ]] pacing in [[patients]] with relatively preserved [[LVEF]] and [[LVEF]]<35%.<ref name="pmid21606084">{{cite journal |vauthors=Brignole M, Botto G, Mont L, Iacopino S, De Marchi G, Oddone D, Luzi M, Tolosana JM, Navazio A, Menozzi C |title=Cardiac resynchronization therapy in patients undergoing atrioventricular junction ablation for permanent atrial fibrillation: a randomized trial |journal=Eur Heart J |volume=32 |issue=19 |pages=2420–9 |date=October 2011 |pmid=21606084 |doi=10.1093/eurheartj/ehr162 |url=}}</ref>
 
* [[His bundle ]] pacing was associated with a significant decrease in [[heart failure]] [[hospitalizations]] when [[ventricular]] pacing >20% compared with [[RV]] pacing.<ref name="pmid25828601">{{cite journal |vauthors=Lustgarten DL, Crespo EM, Arkhipova-Jenkins I, Lobel R, Winget J, Koehler J, Liberman E, Sheldon T |title=His-bundle pacing versus biventricular pacing in cardiac resynchronization therapy patients: A crossover design comparison |journal=Heart Rhythm |volume=12 |issue=7 |pages=1548–57 |date=July 2015 |pmid=25828601 |doi=10.1016/j.hrthm.2015.03.048 |url=}}</ref><ref name="pmid24509688">{{cite journal |vauthors=Kronborg MB, Mortensen PT, Poulsen SH, Gerdes JC, Jensen HK, Nielsen JC |title=His or para-His pacing preserves left ventricular function in atrioventricular block: a double-blind, randomized, crossover study |journal=Europace |volume=16 |issue=8 |pages=1189–96 |date=August 2014 |pmid=24509688 |doi=10.1093/europace/euu011 |url=}}</ref>
 
* Among [[patients]] with [[AF]] who undergo [[atrioventricular node]] ablation to control rapid [[ventricular]] rates, implantation of [[physiologic]] pacing ([[CRT]] or [[His bundle]]) was associated with improvement in  6-minute walk distances and [[quality of life]] compared with [[RV]] [[pacing]].<ref name="pmid29220422">{{cite journal |vauthors=Vijayaraman P, Subzposh FA, Naperkowski A |title=Atrioventricular node ablation and His bundle pacing |journal=Europace |volume=19 |issue=suppl_4 |pages=iv10–iv16 |date=December 2017 |pmid=29220422 |doi=10.1093/europace/eux263 |url=}}</ref>
*In [[patients]] with permanent [[AF]] when [[rhythm]] control is not planned , pacing and sensing of [[atrium ]] is not recommended.<ref name="pmid12495391">{{cite journal |vauthors=Wilkoff BL, Cook JR, Epstein AE, Greene HL, Hallstrom AP, Hsia H, Kutalek SP, Sharma A |title=Dual-chamber pacing or ventricular backup pacing in patients with an implantable defibrillator: the Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial |journal=JAMA |volume=288 |issue=24 |pages=3115–23 |date=December 2002 |pmid=12495391 |doi=10.1001/jama.288.24.3115 |url=}}</ref>




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{| style="cellpadding=0; cellspacing= 0; width: 600px;"
{| style="cellpadding=0; cellspacing= 0; width: 600px;"
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| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for temporary pacing for bradycardia associated atrioventricular block'''
| style="padding: 0 5px; font-size: 100%; background: #4682B4; color: #FFFFFF;" align=center |'''Recommendations for permanent  pacing techniques and methods for bradycardia associated atrioventricular block'''
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''  ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence A]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[sinus node dysfunction ]] or [[atrioventricular block]], [[dual chamber permanent pacing]] is preferred over single chamber [[ventricular pacing]]<br>
❑ [[Single chamber]] [[ventricular pacing]] is recommended in [[patients]] with No need for frequent pacing, significant comorbidities, NO clinical benefit of [[dual chamber pacing]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''  ([[ACC AHA guidelines classification scheme|Class I, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In the presence of  [[pacemaker syndrome]] in single chamber [[pace maker]], revising single chamber [[pace maker]] to dual chamber [[pacemaker]] is recommended<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''  ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑[[Cardiac resynchronization therapy]] or [[His bundle]] [[pacing]] over [[right ventricular]] pacing is recommended in [[patients]] with [[LVEF]] between 36% -50 % who need more than 40% [[ventricular pacing]]<br>
❑ [[Right ventricular pacing]] is recommended over [[CRT]] or [[His bundle]] pacing in [[patients]] with [[LVEF]] between 36%-50% who require less than 40% [[ventricular pacing]]<br>
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''  ([[ACC AHA guidelines classification scheme|Class IIb, Level of Evidence B]]):'''
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[atrioventricular block]] at the level of [[atrioventricular node]], [[His bundle pacing]] may be considered for maintaining physiologic activation of [[ventricle]]<br>
|-
|-
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |''' Medical therapy ([[ACC AHA guidelines classification scheme|Class IIa, Level of Evidence B]]):'''
|style="font-size: 100; padding: 0 5px; background: #B8B8B8" align=left |'''  ([[ACC AHA guidelines classification scheme|Class III, Level of Evidence C]]):'''
|-
|-
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
|style="padding: 0 5px; font-size: 100%; background: #F5F5F5; width: 70%" align=left|
❑ In [[patients]] with [[symptomatic]] [[bradycardia]]  associated second or [[third degree atrioventricular block]], refractory to [[medications]], [[ temporary transvenous pacing]] is recommended to increase [[heart rate]] and improve [[symptoms]]<br>  
❑ For [[patients]] with permanent or persistent [[AF]] when the strategy of [[rhythm]] control is not planned, [[atrial lead]] should not be implanted<br>
 
|}
|}
<ref name="KusumotoSchoenfeld2019">{{cite journal|last1=Kusumoto|first1=Fred M.|last2=Schoenfeld|first2=Mark H.|last3=Barrett|first3=Coletta|last4=Edgerton|first4=James R.|last5=Ellenbogen|first5=Kenneth A.|last6=Gold|first6=Michael R.|last7=Goldschlager|first7=Nora F.|last8=Hamilton|first8=Robert M.|last9=Joglar|first9=José A.|last10=Kim|first10=Robert J.|last11=Lee|first11=Richard|last12=Marine|first12=Joseph E.|last13=McLeod|first13=Christopher J.|last14=Oken|first14=Keith R.|last15=Patton|first15=Kristen K.|last16=Pellegrini|first16=Cara N.|last17=Selzman|first17=Kimberly A.|last18=Thompson|first18=Annemarie|last19=Varosy|first19=Paul D.|title=2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society|journal=Circulation|volume=140|issue=8|year=2019|issn=0009-7322|doi=10.1161/CIR.0000000000000628}}</ref>


== Surgery ==
A permanent pacemaker insertion is a minimally invasive procedure. The procedure is typically performed in a cardiac catheterization lab or an operating room. Transvenous access to the heart chambers under local anesthesia is the preferred technique, most commonly via the [[Subclavian veins|subclavian vein]], the [[cephalic vein]], or the [[internal jugular vein]] or the [[femoral vein]].The pacing generator is most commonly placed subcutaneously in the pre-pectoral region. Placement of pacemaker leads, surgically via [[thoracotomy]], is rarely used these days.
== Types of permanent pacemaker systems ==
All cardiac pacemakers consist of two components: a pulse generator that provides the electrical impulse for myocardial stimulation; and one or more electrodes that deliver the electrical impulse to the myocardium. The original cardiac pacing system was used to place surgically in the abdomen. Over time, pacemaker systems evolved to predominantly placing the pulse generator in the infraclavicular region of the chest with transvenous-placed endocardial leads. Transvenous leads have potential long-term complications, including [[venous thrombosis]], [[infection]], and lead malfunction. Leadless cardiac pacing systems are currently in development and offer the promise of long-term pacing capability without lead-associated complications.
=== Transvenous systems ===
The majority of cardiac pacing systems use transvenous electrodes to transmit pacing impulses from the generator to the myocardium. Transvenous leads are usually placed percutaneously or with a cephalic cutdown, without the need for intrathoracic surgery. Long term complications of transvenous electrodes include infection,venous thrombosis, lead malfunction, and tricuspid valve injury.
=== Epicardial systems ===
Epicardial cardiac pacemaker systems utilize a pulse generator with leads attached surgically directly to the epicardial surface of the heart. These systems are occasionally used in patients with vascular access problems and have been replaced by transvenous systems. 
=== '''Leadless systems''' ===
In response to the limitations of existing pacings systems, leadless systems are developed. Leadless systems consist of a self-contained system that includes both the pulse generator and the electrode within a single unit that is placed into the right ventricle via a transvenous approach. Leadless cardiac pacing system was approved in April 2016 in the United States<ref><nowiki>http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm494390.htm</nowiki> </ref><br />
==References==
==References==
{{reflist|2}}
{{reflist|2}}

Latest revision as of 05:27, 2 July 2021

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2] Cafer Zorkun, M.D., Ph.D. [3]; Raviteja Guddeti, M.B.B.S. [4] Soroush Seifirad, M.D.[5] Qasim Khurshid, M.B.B.S [5]

Overview

Cardiac pacemakers are effective treatments for a variety of cardiac conduction abnormalities and can reestablish adequate circulation by generating appropriate heart rate and cardiac response. Two main factors guide the majority of decisions regarding permanent pacemaker insertion. First is the association of symptoms with arrhythmia, and second is the potential for progression of the rhythm disturbance. Symptoms related to atrioventricular block are determining factor of placing permanent pacemaker, regardless of the level of atrioventricular block. Permanent pacemaker is warranted if the site of atrioventricular block is Infranodal, regardless of the presence or absence of symptoms. Temporary transvenous pacing is used to provide hemodynamic support or back-up pacing to prevent asystole. If atrioventricular block seems to be irreversible, it is better to proceed directly with permanent pacemaker implantation.

Surgery

Recommendation for implantation of temporary pacing for bradycardia associated atrioventricular block

[1]


Recommendations for temporary pacing for bradycardia associated atrioventricular block
Medical therapy (Class IIa, Level of Evidence B):

❑ In patients with symptomatic bradycardia associated second or third degree atrioventricular block, refractory to medications, temporary transvenous pacing is recommended to increase heart rate and improve symptoms

Comment

Recommendation for placement of permanent pacing

Recommendations for permanent pacing for chronic management of Bradycardia Attributable to Atrioventricular Block
(Class I, Level of Evidence B):

❑Permanent pacing is recommended in patients with acquired second degree mobitz type2 atrioventricular block, high grade atrioventricular block, third degree atrioventricular block, regardless of symptoms that are not related to reversible causes
❑ permanent pacing with additional defibrillator capacity is needed in patients with neuromuscular disease associated conduction disorder such as myotonic dystrophy type1 or kearn sayre syndrome and presence of second degree atrioventricular block, third degree atioventricular block, HV interval of 70 ms or greater, regardless of symptoms if life expectancy>1 year

( Class I, Level of Evidence C) :

❑ Permanent pacing is recommended in patients with permanent atrial fibrillation and symptomatic bradycardia
❑ In patients with symptomatic atrioventricular block associated with necessary medications which there is not alternative treatment, permanent pacing is needed

(Class IIa, Level of Evidence B)

❑ In patients with cardiac sarcoidosis and amyloidosis and evidence of mobitz type 2 atrioventricular block, high grade atrioventricular block, third degree atrioventricular block , permanent pacing with additional defibrillator capacity is reasonable if life expectancy>1 year
❑ In patients with lamin A/C mutation such as limb girdle, emery driefuss muscular dystrophies with PR interval>240 ms and LBBB, permanent pacing with additional defibrillator capacity is reasonable if life expectancy >1 year

(Class IIa, Level of Evidence C)

❑ In patients with symptomatic first degree atrioventricular block or motitz tyoe 1 atrioventricular block, permanent pacing is recommended

(Class IIb, Level of Evidence C)

❑ Permanent pacing with additional defibrillator capacity is recommended in patients with neuromuscular disease including myotonic dystrophy type1 with PR interval >240ms , QRS duration >120 ms, fascicular block if life expectancy>1 year

The above table adopted from 2018 AHA/ACC/HRS Guideline[1]

Notes



Management of bradycardia or pauses attributable to chronic atrioventricular block algorithm

 
 
 
Atrioventricular block
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Complete heart block (aquired)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Permanent pacing (class1)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider risk for ventricular arrhythmia (class1)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cardiac resynchronization therapy
  • Is LVEF<35%?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
NO
 
Yes
  • Medical therapy
    •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Yes
     
    		N0
  • Permanent atrial fibrillation
    •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    		Yes
     
    		NO
  • Dual chamber pacing (class1)
    •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    		LVEF>50%
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    		Yes
     
    		NO
  • Is predicted pacing <40%
    •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    		NO
     
    		Yes
  • Righr ventricular pacing (class2a)
    •  
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    		His bundle pacing (class2b)
     
     
     
     


    The above algorithm adopted from 2018 AHA/ACC/HRS Guideline[1]

    Methods of implantation permanent pacing



    Recommendations for permanent pacing techniques and methods for bradycardia associated atrioventricular block
    (Class I, Level of Evidence A):

    ❑ In patients with sinus node dysfunction or atrioventricular block, dual chamber permanent pacing is preferred over single chamber ventricular pacing
    ❑ Single chamber ventricular pacing is recommended in patients with No need for frequent pacing, significant comorbidities, NO clinical benefit of dual chamber pacing

    (Class I, Level of Evidence B):

    ❑ In the presence of pacemaker syndrome in single chamber pace maker, revising single chamber pace maker to dual chamber pacemaker is recommended

    (Class IIa, Level of Evidence B):

    ❑Cardiac resynchronization therapy or His bundle pacing over right ventricular pacing is recommended in patients with LVEF between 36% -50 % who need more than 40% ventricular pacing
    ❑ Right ventricular pacing is recommended over CRT or His bundle pacing in patients with LVEF between 36%-50% who require less than 40% ventricular pacing

    (Class IIb, Level of Evidence B):

    ❑ In patients with atrioventricular block at the level of atrioventricular node, His bundle pacing may be considered for maintaining physiologic activation of ventricle

    (Class III, Level of Evidence C):

    ❑ For patients with permanent or persistent AF when the strategy of rhythm control is not planned, atrial lead should not be implanted

    [1]

    References

    1. ↑ 1.0 1.1 1.2 1.3 Kusumoto, Fred M.; Schoenfeld, Mark H.; Barrett, Coletta; Edgerton, James R.; Ellenbogen, Kenneth A.; Gold, Michael R.; Goldschlager, Nora F.; Hamilton, Robert M.; Joglar, José A.; Kim, Robert J.; Lee, Richard; Marine, Joseph E.; McLeod, Christopher J.; Oken, Keith R.; Patton, Kristen K.; Pellegrini, Cara N.; Selzman, Kimberly A.; Thompson, Annemarie; Varosy, Paul D. (2019). "2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society". Circulation. 140 (8). doi:10.1161/CIR.0000000000000628. ISSN 0009-7322.
    2. ↑ Murphy JJ (May 1996). "Current practice and complications of temporary transvenous cardiac pacing". BMJ. 312 (7039): 1134. doi:10.1136/bmj.312.7039.1134. PMC 2350635. PMID 8620131.
    3. ↑ Morrison LJ, Long J, Vermeulen M, Schwartz B, Sawadsky B, Frank J, Cameron B, Burgess R, Shield J, Bagley P, Mausz V, Brewer JE, Dorian P (March 2008). "A randomized controlled feasibility trial comparing safety and effectiveness of prehospital pacing versus conventional treatment: 'PrePACE'". Resuscitation. 76 (3): 341–9. doi:10.1016/j.resuscitation.2007.08.008. PMC 7126680 Check |pmc= value (help). PMID 17933452.
    4. ↑ Shaw DB, Kekwick CA, Veale D, Gowers J, Whistance T (June 1985). "Survival in second degree atrioventricular block". Br Heart J. 53 (6): 587–93. doi:10.1136/hrt.53.6.587. PMC 481819. PMID 4005079.
    5. ↑ Facenda-Lorenzo M, Hernández-Afonso J, Rodríguez-Esteban M, de León-Hernández JC, Grillo-Pérez JJ (March 2013). "Cardiac manifestations in myotonic dystrophy type 1 patients followed using a standard protocol in a specialized unit". Rev Esp Cardiol (Engl Ed). 66 (3): 193–7. doi:10.1016/j.rec.2012.08.011. PMID 24775453.
    6. ↑ Dhingra RC, Denes P, Wu D, Chuquimia R, Rosen KM (April 1974). "The significance of second degree atrioventricular block and bundle branch block. Observations regarding site and type of block". Circulation. 49 (4): 638–46. doi:10.1161/01.cir.49.4.638. PMID 4817704.
    7. ↑ Dargie HJ (September 2000). "Design and methodology of the CAPRICORN trial - a randomised double blind placebo controlled study of the impact of carvedilol on morbidity and mortality in patients with left ventricular dysfunction after myocardial infarction". Eur J Heart Fail. 2 (3): 325–32. doi:10.1016/s1388-9842(00)00098-2. PMID 10938495.
    8. ↑ Zhou Y, Lower EE, Li HP, Costea A, Attari M, Baughman RP (January 2017). "Cardiac Sarcoidosis: The Impact of Age and Implanted Devices on Survival". Chest. 151 (1): 139–148. doi:10.1016/j.chest.2016.08.1457. PMID 27614001.
    9. ↑ van Rijsingen IA, Nannenberg EA, Arbustini E, Elliott PM, Mogensen J, Hermans-van Ast JF, van der Kooi AJ, van Tintelen JP, van den Berg MP, Grasso M, Serio A, Jenkins S, Rowland C, Richard P, Wilde AA, Perrot A, Pankuweit S, Zwinderman AH, Charron P, Christiaans I, Pinto YM (April 2013). "Gender-specific differences in major cardiac events and mortality in lamin A/C mutation carriers". Eur J Heart Fail. 15 (4): 376–84. doi:10.1093/eurjhf/hfs191. PMID 23183350.
    10. ↑ Hasselberg NE, Edvardsen T, Petri H, Berge KE, Leren TP, Bundgaard H, Haugaa KH (April 2014). "Risk prediction of ventricular arrhythmias and myocardial function in Lamin A/C mutation positive subjects". Europace. 16 (4): 563–71. doi:10.1093/europace/eut291. PMID 24058181.
    11. ↑ Lader JM, Park D, Aizer A, Holmes D, Chinitz LA, Barbhaiya CR (March 2018). "Slow pathway modification for treatment of pseudo-pacemaker syndrome due to first-degree atrioventricular block with dual atrioventricular nodal physiology". HeartRhythm Case Rep. 4 (3): 98–101. doi:10.1016/j.hrcr.2017.10.003. PMC 5919070. PMID 29707483.
    12. ↑ Dretzke J, Toff WD, Lip GY, Raftery J, Fry-Smith A, Taylor R (2004). "Dual chamber versus single chamber ventricular pacemakers for sick sinus syndrome and atrioventricular block". Cochrane Database Syst Rev (2): CD003710. doi:10.1002/14651858.CD003710.pub2. PMC 8095057 Check |pmc= value (help). PMID 15106214.
    13. ↑ Brignole M, Botto G, Mont L, Iacopino S, De Marchi G, Oddone D, Luzi M, Tolosana JM, Navazio A, Menozzi C (October 2011). "Cardiac resynchronization therapy in patients undergoing atrioventricular junction ablation for permanent atrial fibrillation: a randomized trial". Eur Heart J. 32 (19): 2420–9. doi:10.1093/eurheartj/ehr162. PMID 21606084.
    14. ↑ Lustgarten DL, Crespo EM, Arkhipova-Jenkins I, Lobel R, Winget J, Koehler J, Liberman E, Sheldon T (July 2015). "His-bundle pacing versus biventricular pacing in cardiac resynchronization therapy patients: A crossover design comparison". Heart Rhythm. 12 (7): 1548–57. doi:10.1016/j.hrthm.2015.03.048. PMID 25828601.
    15. ↑ Kronborg MB, Mortensen PT, Poulsen SH, Gerdes JC, Jensen HK, Nielsen JC (August 2014). "His or para-His pacing preserves left ventricular function in atrioventricular block: a double-blind, randomized, crossover study". Europace. 16 (8): 1189–96. doi:10.1093/europace/euu011. PMID 24509688.
    16. ↑ Vijayaraman P, Subzposh FA, Naperkowski A (December 2017). "Atrioventricular node ablation and His bundle pacing". Europace. 19 (suppl_4): iv10–iv16. doi:10.1093/europace/eux263. PMID 29220422.
    17. ↑ Wilkoff BL, Cook JR, Epstein AE, Greene HL, Hallstrom AP, Hsia H, Kutalek SP, Sharma A (December 2002). "Dual-chamber pacing or ventricular backup pacing in patients with an implantable defibrillator: the Dual Chamber and VVI Implantable Defibrillator (DAVID) Trial". JAMA. 288 (24): 3115–23. doi:10.1001/jama.288.24.3115. PMID 12495391.

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