▪ Acute myocardial infarction
▪ Pacing after cardiac surgery,transcatheter aortic
valve implantation,and heart transplantation.
▪ Pacing and cardiac resynchronization therapy in
children and in congenital heart disease.
▪ Pacing in hypertrophic cardiomyopathy.
▪ Pacing in rare diseases.
▪ Pacing in pregnancy.
▪ Pacing for ﬁrst-degree atrioventricular block
Acute myocardial infarction
▪ Incidence 3.2% after PCI and thrombolytics.
▪ AWMI associated high degree AV block is
always below Hiss bundle , while IWMI usually
above Hiss bundle .
▪ Usually resolve spontaneously within 2-7 days.
▪ 9% need Permenant pacing later on.
▪ Newely developed Intraventricular condcution
defect usually associated with high mortality due
extensive myonecrosis ... CRT criteria.
▪ AV-block occurs in 1-4% cases :
▪ In 8% after repeated surgery , 20 - 40% in
calcific aortic valve and TV-replacement.
▪ SN-dysfunction may occur in CABG, lateral
atriotomy , trans-septal superior approaches to
▪ In clincial practice 5-7 days observation period
applied before PPM.
▪ AV-block post TAVI reaches 14% , especially
with CoreValve prosthesis .
▪ Independant predictors : use of the CoreValve
prosthesis and evidence of conduction system
dysfunction, either pre- existing RBBB or AV
lock at the time of TAVI.
▪ New-onset persistent LBBB is common
following TAVI, but its significance is unclear.
▪ Even TAVI patients meet the criteria for CRT ,
experience is very limited.
▪ SN-dysfunction is common up to 8% fo cases.
▪ Causes :surgical trauma, sinus node artery
damage, or ischaemia and prolonged cardiac
▪ Av-block is less common and is probably
related to inadequate preservation.
▪ Chronotropic incompetence is always present
following standard orthotopic heart
▪ Observation period several weeks , in clinical
consensus 3 weeks .
May be early manifestations
is sudden cardiac death,
Adam stokes attackes or
Pacing site RV vs LV
Epicardial vs endocardial
The evidence is
limited to case
Single site LV
▪ uncommon in (HCM), but in context,
can suggest speciﬁc aetiologies (for
example, PRKAG2 gene mutations,
Anderson-Fabry disease and
▪ CRT may be considered in
individual cases in which there is
some evidence for systolic ventricular
RV apical pacing
ICD (with active pacing) is preferable in patients with
to ß-blocker therapy or pause-dependent ventricular
arrhythmia according to current ICD guidelines.
once bradycardia appeared , but thromboebolism are
not preventable by pacing.
athy and mitochondrial diseases , pacing with ICD
back-up is the recommended Other types of
▪ Vaginal delivery carries no extra risks in a
mother with congenital complete heart block.
▪ For women who have a stable, narrow,
complex junctional escape rhythm, PM
implantation can be deferred until after delivery.
1st degree AV-block
Prolonged PR interval lead ineffective atrial systole,
and diastolic MR , increased PCWP and pulmonary
DDD -- LV dysfunction
Functional Atrial undersensing --shift of P wave
Rate-adaptive pacing, which periodically assesses the underlying
intrinsic rate to pace just above it, elevation of the pacing rate after
spontaneous atrial ectopy, transient high-rate pacing after mode
switch episodes and increased post-exercise pacing to prevent an
abrupt drop in heart rate.