Indications of pacemaker implantation

1. Who needs a pacemaker ?

2. Sinoatrial node
AV node
Bundle of His
Bundle Branches
Purkinje fibers
Normal Impulse Conduction

3. • Sinus bradycardia.
• Sinus arrest.
• Sinoatrial exit block.
• Sick sinus syndrome.
• Atriovenreicular block
• First degree A-V block.
• Second degree A-V block.
• Third degree A-V block.
Bradyarrhythmias

4. Reversible causes:
• Coronary artery disease.
• Drug induced
• Hypothyroidism
• Electrolyte imbalance

5. Bradycardia

 cardiac
output

 perfusion

Symptoms
AV dyssnchrony

 venous pressures

‘Pacemaker
Syndrome’

Symptoms

6. Symptoms of Bradycardia
• Related to organ hypo-perfusion and include:
– Dizziness
– Fainting (syncope) or near-fainting
– Confusion
– Tiredness (fatigue)
– Shortness of breath
– Palpitations
– Chest pain (angina)
– Some people with bradycardia do not have
symptoms

7. Diagnosis of bradyarrhythmia
• Standard ECG when persistent.
• More prolonged ECG recordings
(Holter monitoring or loop recorder) when
intermittent.
• Provocative testing & (EPS) may be required
when a bradycardia is suspected but not
documented

14. PWB more 450 msec (133 b/min)

18. Pacing device choice
Single chamber versus Dual Chamber

19. Concept: Deleterious Effect of RV pacing
• Previous studies have clearly shown that RV apical
pacing might have deleterious effects on cardiac
structure and function. w156,w159
• Moreover, different clinical trials have shown that
there was a positive correlation between the rate of
RV pacing and the occurrence of adverse events.
17,w160 – w162

23. Device

25. Pacing in special situation.

26. Pacing in acute myocardial infarction.

27. Pacing after cardiac surgery

28. Pacing therapy in pediatric patients and
congenital heart disease

29. Pacing in hypertrophic cardiomyopathy

30. Take home message
• Don't discuss indications of pacing before exclusion of
reversible causes.
• 2nd &3rd degree AV block, whatever persistent or
intermittent ,symptomatic or not is an indication of
pacing.
• When it comes to sinus node disease, the decision is
strongly related to symptom.
• Unexplained syncope should be carefully
investigated.

31. Thank you