This document discusses indications for cardiac implantable electronic devices (CIEDs) such as pacemakers, cardiac resynchronization therapy (CRT), and implantable cardioverter defibrillators (ICDs) according to guidelines. It covers classifications of bradyarrhythmias and indications for pacing in various conditions such as persistent bradycardia. Indications for CRT and ICDs are also outlined based on left ventricular ejection fraction, heart failure class, and other factors. Current health insurance reimbursement policies in Taiwan for these devices are also summarized.

1. 心臟植入性電子儀器(CIED)之適
應症
“Indications for CIED”
亞東紀念醫院 林恆旭 醫師

2. Outline
 Indications for pacing
 Indications for cardiac resynchronization
therapy (CRT)
 Indications for intra-cardiac defibrillator
(ICD) therapy
Ref:
• 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy
• 2012 ACCF/AHA/HRS Focused Update of the 2008 Guidelines for Device-Based
Therapy of Cardiac Rhythm Abnormalities

3. Outline
 Indications for pacing
 Indications for cardiac resynchronization
therapy (CRT)
 Indications for intra-cardiac defibrillator
(ICD) therapy

4. Classifications of Bradyarrhythmias
There are two types of bradyarrhythmias
Sinus node
AV node

5. Sinus node dysfunction
 Sinus Arrest
 Sinus Bradycardia

6. Sinus node dysfunction
 Chronotropic Incompetence
 Tachybrady syndrome

7. AV node dysfunction
 First Degree AV block
 Second Degree AV block
 Mobitz Type 1 – Wenckebach
 Mobitz Type 2
 Third Degree AV block – Complete heart
block
 Bifasicular/Trifasicular block

8. First-Degree AV Block
 PR interval > 200 ms
 Delayed conduction through the AV Node

9. Second-Degree AV Block –
Mobitz I (Wenckebach block)
 Progressive prolongation of the PR interval
until there is failure to conduct and a
ventricular beat is dropped

10. Second-Degree AV Block –
Mobitz II
 Regularly dropped ventricular beats
 2:1 block (2 P-waves for every 1 QRS complex)

11. Third-Degree AV Block
Complete Heart Block
 No impulse conduction from the atria to
the ventricles

12. Fascicular Block
Right bundle branch block
and left anterior hemiblock
Right bundle branch
block and left
posterior hemiblock
Complete left bundle
branch block

13. Classifications of Bradyarrhythmias
There are two types of bradyarrhythmias
Sinus node
AV node

16. Indications for Pacing in Persistent
Bradycardia

17. Indication for Pacing in Intermittent
Documented Bradycardia

18. BBB and Unexplained Syncope
CSM: carotid sinus massage;
ILR =implantable loop recorder.

19. Indication for Pacing in BBB

20. Indication for Pacing in
Undocumented Reflex Syncpe

21. Indication in Unexplained
Syncope

22. Common Pacing Indications
 Sinus Node Disease (SND), or Sick Sinus
Syndrome
 High degree AV Block (Mobitz II & 3rd
AVB)
 Chronotropic Incompetence
Epstein et al. “ACC/AHA/HRS Guidelines for Device-Based Therapy.” JACC Vol. 51, No. 21, 2008.

23. Choice of Pacing Mode and
Programming

25. Optimal Pacing Mode
AVM: AV delay management

26. 現行健保給付規定

27. Outline
 Indications for pacing
 Indications for cardiac resynchronization
therapy (CRT; 心臟再同步化治療)
 Indications for intra-cardiac defibrillator
(ICD) therapy

29. Indications for CRT in patients with
sinus rhythm

30. Indications for CRT in patients with
permanent Afib

31. Indications for CRT in patients with
conventional pacemaker indications
and heart failure

32. 現行健保給付規定
 應事先審查。
 正常竇房節心律，LVEF<=35%且CLBBB(QRS寬度
>=0.12sec)，且NYHA Functional Class III, IV
及經適當藥物治療仍不能改善之病患。
 心房顫動之病患， LVEF<=35%且CLBBB(QRS寬度
>=0.12sec)，且NYHA Functional Class III, IV
及經適當藥物治療仍不能改善之病患。
 心室節律器依賴之病患，LVEF<=35%，NYHA
Functional Class III, IV及經適當藥物治療仍
不能改善者。

34. Outline
 Indications for pacing
 Indications for cardiac resynchronization
therapy (CRT)
 Indications for intra-cardiac defibrillator
(ICD) therapy

35. Class I Recommendations
 Level of Evidence: A
 With LVEF ≤ 35% due to prior MI who are at least 40
days post-MI and are in NYHA Functional Class II or
III
 With LV dysfunction due to prior MI who are at least
40 days post-MI, have an LVEF ≤ 30%, and are in
NYHA Functional Class I
 Who are survivors of cardiac arrest due to VF or
hemodynamically unstable sustained VT after
evaluation to define the cause of the event and to
exclude any completely reversible causes

36. Class I Recommendations
 Level of Evidence: B
 With nonischemic DCM who have an LVEF ≤ 35% and
who are in NYHA Functional Class II or III
 With nonsustained VT due to prior MI, LVEF < 40%,
and inducible VF or sustained VT at
electrophysiological study
 With structural heart disease and spontaneous
sustained VT, whether hemodynamically stable or
unstable
 With syncope of undetermined origin with clinically
relevant, hemodynamically significant sustained VT or
VF induced at electrophysiological study

37. Class IIa Recommendations
 Level of Evidence: B
 To reduce SCD in patients with Long QT
Syndrome who are experiencing syncope
and/or VT while receiving beta blockers

38. Class IIa Recommendations
 Level of Evidence: C
 With unexplained syncope, significant LV dysfunction, and
nonischemic DCM
 With sustained VT and normal or near-normal ventricular
function
 With catecholaminergic polymorphic VT who have syncope
and/or documented sustained VT while receiving beta blockers
 For the prevention of SCD in patients with ARVD/C who have
one or more risk factors for SCD
 With HCM who have one or more major risk factors for SCD
 With Brugada syndrome who have had syncope or documented
VT that has not resulted in cardiac arrest
 With cardiac sarcoidosis, giant cell myocarditis, or Chagas
disease
 For nonhospitalized patients awaiting transplantation

39. 現行健保給付規定
 申報規範：
 操作醫院應事先報備作業流程及持續照護計畫。
 原則採事後逐案審查，個別醫院如經審查評估不符
治療指引，則改採逐案事前審查。
 給付規定：
 嚴重心室頻脈、心室顫動導致猝死可能或昏迷。
 反覆發作之持續性心室頻脈。
 高危險性心臟血管疾病或遺傳性疾病，如：曾經心肌
梗塞併左心室射出分率≦40%，long QT syndrome，
short QT syndrome，Brugada syndrome，idiopathic
ventricular fibrillation，arrhythmogenic right
ventricle dysplasia，catecholaminergic
polymorphic ventricular tachycardia，肥厚性心肌
症，擴張性心肌症等，且臨床合併心室快速不整
脈或合併猝死症之家族史者。

40. 現行健保給付規定
 心臟整流去顫器結合心房同步雙心室節律器之給
付規定為：符合「心臟整流去顫器」之給付規定，
且合乎「心房同步雙心室節律器」之給付規定者。
 已通過同步雙心室節律器事前申請者，於裝置時
突發嚴重心室不整脈者，可改裝ICD或CRTD，以維
護病患安全，並於事後補報。

41. 現行健保給付規定
 不宜列入項目：
 末期心臟衰竭，無法藥物控制又非心臟移植對象者。
 猝死可能經急救後，無意識恢復之患者。
 末期疾病患者且存活不足六個月者。
 惡性且任何治療無法控制(intractable)之心室頻脈或
心室顫動。
 依據「特定醫療技術檢查檢驗醫療儀器施行或使
用管理辦法」，自101.9.1.解除登記列管。配合
將操作醫院、醫師資格等刪除。

42. Thank You