Who needs a pacemaker?
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Indications of pacemaker implantation Presented at the 7th annual institute conference of dysrhythmia. Cairo, Egypt.
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Who needs a pacemaker?
- 1. Who needs a pacemaker ? Why so serious? Yasmeen Kamal Tanta Rhythm Group Department of cardiovascular medicine Tanta University
- 2. “In every moment of choice, you create a new destiny.”
- 3. Case Number 1 A 55 year old gentleman with unremarkable medical history was presented with Dizziness , weakness and easy fatigability progressively increased over the past 3 months . His laboratory data was all normal including TSH , electrolytes and cardiac enzymes. Echocardiography showed grade I DD. Coronary angiography was normal.
- 4. ECG
- 5. What’s next ? Invasive EP study Tilt table testing PM implantation Reassurance
- 7. The answer is Invasive EP study Tilt table testing PM implantation Reassurance
- 8. ACCORDING TO ESC GUIDELINES OF “CARDIAC PACING AND CARDIAC RESYNCHRONIZATION THERAPY 2013”
- 9. Which type of device should be implanted in this case? VVI VVIR DDD CRT
- 10. The answer is VVI VVIR DDD CRT
- 11. Case Number 2 A 65 year old gentleman had aortic valve replacement 5 years before he was presented to outpatient clinic with a sudden fall during exercise. His laboratory data was all normal , no current medications except warfarin and his INR was 3.3 Echocardiography showed well functioning prosthetic valve and good LV systolic function. His ECG showed : second degree type 2 AV block with HR around 35 bpm
- 12. He was given Atropine 500 mcg and returned to SR
- 13. What’s next ? Discharge on oral salbutamol &follow up Holter monitoring Invasive EP study PM implantation
- 14. The answer is Discharge on oral salbutamol &follow up Holter monitoring Invasive EP study PM implantation
- 18. Case Number 3 A 60 year old gentleman , diabetic , not hypertensive , presented with true syncope Echocardiography showed sclero-calcific aortic valve with mild AS , grade I DD His ECG on admission:
- 19. ECG
- 20. What’s next ? Invasive EP study Medical TTT Device implantation Holter Monitoring
- 21. The answer is Invasive EP study Medical TTT Device implantation Holter monitoring
- 23. Alternating BBB (also known as bilateral BBB) refers to situations in which clear ECG evidence for block in all three fascicles is manifested on successive ECGs. There is general consensus these patients progress rapidly toward AV block. Therefore a PM is usually implanted as soon as the alternating BBB is detected, even in the
- 24. Case Number 4 A 50 year old gentleman , not diabetic , not hypertensive , smoker presented to ER with light headedness and dizziness lasted for few seconds with loss of balance. His laboratory data was normal including cardiac enzymes Echocardiography showed EF 65 % Neurological examination was free
- 25. ECG
- 26. What’s next ? Invasive EP study Non invasive tests (Tilt, Holter , ILR , .. ) PM implantation
- 27. The answer is Invasive EP study Non invasive tests (Tilt, Holter , ILR , .. ) PM implantation
- 28. Two months later ,this patient came to ER with similar attack and associated with head trauma and face bruises He described total loss of consciousness while he was climbing down the stairs and fell down on his head , he regained his consciousness few seconds after.
- 30. After revising his records , Reflex sycnope was excluded after a negative tilt testing and carotid massage were done So He was scheduled for an EP study which revealed HV interval of 90 msec.
- 33. Indication for cardiac pacing in patients with reflex syncope
- 35. Carotid sinus syncope syncope with carotid sinus massage yielding either: asystole of >3 sec or fall in systolic blood pressure of >50 mmHg, or both, and reproduction of the spontaneous syncope. In order to be as diagnostic as possible, massage is to be performed in supine and standing and pacing (dual chamber) is indicated when >6 sec asystole occurs with reproduction of the spontaneous syncope.
- 36. Case Number 5 A 32 year old lady, with unremarkable medical history presented to outpatient clinic complaining from recurrent episodes of dizziness and true syncope Her laboratory data was normal Resting ECG was normal sinus rhythm at HR 45 bpm Echocardiography was normal and showed EF of 60 % Neurological examination was free A holter monitoring was arranged for her and ….
- 37. Rhythm strip from Holter monitoring
- 38. That was a symptomatic AV block resulting in 9 seconds pause NB : In cases with history of syncope and Asymptomatic pauses more than 6 seconds Pacing is class IIa indication
- 39. Case Number 6 A 45 year old gentleman , a manual worker ,with non remarkable medical history was referred to arrhythmia clinic for pre operative evaluation before elective cholecystectomy . His monitored heart rate on admission was 40 bpm. Pre-operative lab markers were normal.
- 40. ECG Sinus bradycardia Detailed history taking showed there are no symptoms associated with rest nor with exercise.
- 41. What’s next ? Invasive EP study PM implantation Exercise ECG
- 42. The answer is Invasive EP study PM implantation Exercise ECG
- 44. Remember : When it comes to sinus node disease ,, the decision is strongly related to symptoms
- 46. Case Number 7 A 22 year old man was referred to you with this ECG while he was evaluated before his military service
- 47. Case Number 7 The patient reported that he is feeling well and is not experiencing any current symptoms. He stated that he is not having chest discomfort, difficulty of breathing, or dizziness. He mentioned he was told at the age of 3 that his heart rate is a little bit slow but it was ok. His medical history is unremarkable. And he is not on any regular medications. Echocardiography was normal EF is 65 %
- 48. Apparently it is Congenital CHB, so what’s next? Holter monitoring PM implantation Exercise ECG Invasive EP study
- 49. The answer is Holter monitoring PM implantation Exercise ECG Invasive EP study
- 50. Prophylactic pacing is indicated in Asymptomatic patients with Congenital CHB with any of the following risk conditions: • Ventricular dysfunction • prolonged QTc interval • complex ventricular ectopy • wide QRS escape rhythm • ventricular rate <50 b.p.m. • ventricular pauses >three-fold the cycle length of the underlying rhythm.
- 51. Case Number 8 18 year old asymptomatic athlete came to outpatient clinic for cardiac evaluation before Olympics
- 52. Do you think his condition is pathological and he is not fit for competitive sports ? Yes No
- 56. His ECG during Exercise
- 57. Take Home Messages Don’t discuss indications of pacing before exclusion of reversible causes. 2nd and 3rd degree AV block ,whether persistent or intermittent , symptomatic or not is an indication of Pacing. When it comes to sinus node disease ,,the decision is strongly related to symptoms. Unexplained syncope should be carefully investigated. can you imagine life without Pacemakers ?!
- 58. Any Questions ?
- 59. Remember
- 60. Thank You
Hinweis der Redaktion
- Some uncontrolled and non-randomized studies have suggested that a reduction of the AV timing using conventional DDD PM would improve symptoms and patients’ functional status, especially in patients with preserved LV function. The improvement with DDD pacing is directly linked to the improvement in LV filling time.w14,w16 There are some potentially harmful consequences of conventional DDDpacing. The first one is that permanent RV pacing may enhance LV dysfunction. To avoid this potential effect, biventricular pacing could be considered, but there is a definitive lack of data to support this concept, especially in patients with narrow QRS and/ or preserved LV function. The systematic use of biventricular pacing is not recommended at this time for this particular indication in the absence of other CRT indications.