Who needs a pacemaker ?Why so serious?

Yasmeen KamalTanta Rhythm Group

Department of cardiovascular medicineTanta University

“In every moment of choice, you create a new

destiny ”.

Case Number 1A 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.

ECG

What’s next?

Invasive EP study Tilt table testing PM implantation Reassurance

The answer is

Invasive EP study Tilt table testing PM implantation Reassurance

ACCORDING TO ESC GUIDELINES OF “CARDIAC PACING AND CARDIAC RESYNCHRONIZATION THERAPY 2013”

Which type of device should be implanted in this case?

VVI VVIR DDD CRT

The answer is

VVI VVIR DDD CRT

Case Number 2A 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 3.3Echocardiography showed well functioning prosthetic valve and good LV systolic function.

His ECG showed : second degree type 2 AV block with HR around 35 bpm

He was given Atropine 500 mcg and returned to SR

What’s next?

Discharge on oral salbutamol &follow up Holter monitoring Invasive EP study PM implantation

The answer is

Discharge on oral salbutamol &follow up Holter monitoring Invasive EP study PM implantation

Case Number 3A 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:

ECG

What’s next?

Invasive EP study Medical TTT Device implantation Holter Monitoring

The answer is

Invasive EP study Medical TTT Device implantation Holter monitoring

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 absence of a history of syncope.

Case Number 4A 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

ECG

What’s next?

Invasive EP study Non invasive tests (Tilt, Holter , ILR , .. ) PM implantation

The answer is

Invasive EP study Non invasive tests (Tilt, Holter , ILR , .. ) PM implantation

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.

After revising his records , Reflex sycnope was excluded after a negative tilt testing and carotid massage were doneSo He was scheduled for an EP study which revealed HV interval of 90 msec.

Indication for cardiac pacing in patients with reflex syncope

Carotid sinus syncopesyncope 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.

Case Number 5A 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 bpmEchocardiography was normal and showed EF of 60 %Neurological examination was free A holter monitoring was arranged for her and ….

Rhythm strip from Holter monitoring

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

Case Number 6A 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.

ECG

Sinus bradycardiaDetailed history taking showed there are no symptoms associated with rest nor with exercise.

What’s next?

Invasive EP study PM implantation Exercise ECG

The answer is

Invasive EP study PM implantation Exercise ECG

Remember :When it comes to sinus node disease ,, the decision is strongly related to symptoms

Case Number 7A 22 year old man was referred to you with this ECG while he was evaluated before his military service

Case Number 7The 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 %

Apparently it is Congenital CHB, so what’s next?

Holter monitoring PM implantation Exercise ECGInvasive EP study

The answer is

Holter monitoringPM implantation Exercise ECG Invasive EP study

Prophylactic pacing is indicated in Asymptomaticpatients 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.

Case Number 818 year old asymptomatic athlete came to outpatient clinic for cardiac evaluation before Olympics

Do you think his condition is pathological and he is not fit for competitive sports ?

Yes

No

The answer is

Yes

No

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His ECG during Exercise

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 ?!

Any Questions?

Remember

Thank You