Who needs a pacemaker ?

Sinoatrial node

AV node

Bundle of His

Bundle Branches

Purkinje fibers

Normal Impulse Conduction

• 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

Reversible causes:

• Coronary artery disease.• Drug induced• Hypothyroidism• Electrolyte imbalance

Bradycardia

cardiac output

perfusion

Symptoms

AV dyssnchrony

venous pressures

‘Pacemaker Syndrome’

Symptoms

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

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

PWB more 450 msec (133 b/min)

Pacing device choiceSingle chamber versus Dual Chamber

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

Device

Pacing in special situation.

Pacing in acute myocardial infarction.

Pacing after cardiac surgery

Pacing therapy in pediatric patients andcongenital heart disease

Pacing in hypertrophic cardiomyopathy

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.

Thank you