Indication for CIED
Cardiovascular center,
Chia-Yi branch, VGH-TC
Liao Ying Chieh
PACEMAKER Pacing against bradycardia
Sick sinus syndrome (SSS)
• Degenerative disease
• Asymptomatic to syncope
• Escape rhythm and symptom
• SCD is extremely rare.
• Same survival whether treatment or not
• Sinus Bradycardia
• Sinus pause
• Bradycardia-Tachycardia
Syndrome
• SA Exit Block
• Symptomatic chronotropic
incompetence
ECG presentation
Treatment consideration
• Symptom ? (not specific)
• Bradycardia ?
• Relationship between symptom and bradycardia
• Pacemaker: for symptom, not for survival.
Class I Indication of PPM in SSS
• Symptomatic bradycardia (clear relationship)
-- irreversible
-- due to necessary medication
• Symptomatic chonotropic incompetence
Class IIA indication of PPM in SSS
• HR < 40/min, with symptom, but the association is not established.
• Unexplained syncope + positive provoked test in EP study.
Class IIB indication of PPM in SSS
• Minimal symptom, and chronic HR < 40/min
Class III contraindication
• No symptom. (Even SSS is diagnosed)
• The symptom is documented in the absence of bradycardia.
AV block
• First, second (type I, II), third degree.
• Supra-his, intra-his, and infra-his.
• Advanced AVB and block below his indicated poor prognosis.
• Whether symptomatic or not, PPM improved survival in advance AV block.
ECG presentation
AV node Supra-his block
Wenckebach phenomenon Affected by endocrine, nerve, and medication
His-Purkinje system Intra-his and infra-his block
All or none conduction Rarely affected by medication.
Level of AV block
◎ ◎
◎
Degree and level of AV block
ADVANCED
Class I indication of PPM in AVB
• Type-II 2° or 3° + any of following
Symptom, HF, low LVEF, cardiomegaly.
intra- or infra- his block.
VT/VF, wide QRS, HR <40/min.
pause > 3 secs in SR or >5 secs in AF.
iatrogenic, neuromuscular disease.
happened during exercise
Class IIA indication of PPM in AVB
• Pure type-II 2° or 3°AV block.
• Type-I 2° AV
--- block at “intra- or infra-his” level
--- Pacemaker syndrome
• 1° AVB
--- Pacemaker syndrome
Class IIB indication of PPM in AVB
• Type-I 2° or 1° with neuromuscular disease
• AV block due to toxin or drug but expected to recur.
Class III contraindication
• 1° AV block without symptom
• Type-I 2° supra-his AV block without symptom
• Reversible cause unlikely to recur
Site of AV block
PPM syndrome IIA No symptom III
IIA
At least IIA Mostly I
Chronic Bi-fascicular Block
× ×
Pre-existed block in 2/3 fascicles
PPM in Chronic Bi-fascicular Block
• Class I: Type-II 2° or 3° AV block alternating BBB (LBBB + RBBB) all 3 fascicles are clinically diseased
• Class IIa: unexplained syncope H-V interval in EPS>100ms
pacing-induced infra-His block in EPS subclinical dysfunction on the 3rd fascicle
• Class IIb: Neuromuscular diseases
• Class III: no AV block only 1 ° AV block no symptom
Hypersensitivity carotid sinus syndrome Neurocardiac disease
• Class I – Recurrent syncope caused by spontaneous carotid
sinus stimulation inducing pause > 3 sec
• Class IIa – Syncope, cardio-inhibitory pause > 3 sec
• Class IIb – Neurocardiogenic syncope with bradycardia,
spontaneously or at tilting table test.
• Class III – no symptoms – effective avoidance behavior
Indication other than bradycardia ?
• Treating PSVT ?? Pace-terminated PSVT if other Tx failed. (IIA) • Preventing Af ?? no such indication. (III) • Preventing VT ?? sustained pause-dependent VT/VF. (I) high-risk congenital long QT syndrome. (IIA) others. (III) • HOCM ?? Refractory symptoms + LVOT obstruction. (IIA)
Conclusion of PPM indication
• SSS: symptom, correlation to bradycardia.
• AV block: advance, intra- and infra-his level.
• Bi-fascicular block: diseased third fascicle ?
• Neuro-cardiac disease: long pause > 3 secs
IMPLANTABLE CARDIOVERTER DEFIBRILLATOR
Therapy on VT/VF
Sudden cardiac death
In US 90% SCD are VT/VF
Key to Survive in SCA
% S
ucc
ess
Time (min)
100
80
90
70
60
50
40
30
20
10
0 1 2 3 4 5 6 7 8 9 10
Success rates decrease 7-10% each minute
Adapted from text: Cummins RO, 1998. Annals of Emergency Medicine 18: 1269-1275.
Recognize cardiac arrest 1 min.
Internal emergency response 1 min.
Call EMS / dispatch vehicle 1 min.
Aid car sent—arrives on scene 6 min.
Locate victim and deliver shock 2 min.
Total Elapsed Time = 11 min.
ICD intervention
Consideration of ICD implantation
• VT/VF Risk stratification. Who is at high risk ?
SCD-HeFT MUSTT MADIT-2
Primary prevention of SCD in ICD
Secondary prevention of SCD in ICD
• Structurally normal heart
CPVT, Brugada, LQT, SQT
• Structurally abnormal heart
DCM, ICM, HCM, ARVD, infiltrate CM
DCM, ICM, HCM, ARVD, infiltrate CM
Class I: Sustained VT/VF
Syncope + inducible VT/VF in EP study
Class IIA:
DCM syncope + poor LV function
HCM syncope, family Hx of SCD, non-sustain VT,
LV wall thick >3cm, BP drop in exercise.
ARVD syncope, Family Hx of SCD, LV involve.
Sarcoidosis, Chagas disase, giant cell myocarditis.
Structurally normal heart CPVT, Brugada, LQT, SQT.
• Class I: hemodynamic unstable VT/VF or SCD
+ medication + survival > 1 yr
• Class IIa: stable sustain VT
syncope.
Contraindication of ICD implantation
• Incessant VT/VF, or reversible cause
• Syncope in normal heart and negative EP study
• Expected survival < 1 year
• NYHA Fc IV, except waiting heart transplantation, (IIA) or CRT-D.
• Psychiatric illness
• Idiopathic VT (can be cured by ablation)
BIVENTRICULAR PACING (CRT) Synchronize the heart
To improve heart failure survival
• ACEI
• Beta-blocker
• CRT (cardiac resynchronize therapy).
Lower ejection fraction LVEF <35%
LV dyssynchrony, QRS> 120 ms
Severe symptom by optimal drug NYHA Fc 3-4
CRT indication in 2008 AHA guideline
Class I
LVEF <35% + QRS > 0.12s + NYHA-Fc III or IVa
Class IIA
LVEF <35% + (NYHA-Fc III or IVa) + V pacing
LVEF <35% + QRS > 0.12s + (NYHA-Fc III or IVa) +Af
COMPANION trial CARE-HF trial
RAFT trial
• 1798 P’t, CRT-D vs. ICD
• Inclusion: NYHA Fc II ~ III
LVEF 30%
QRS >120 ms
• Follow-up: 40 months
• End-point: mortality + HF hospitalization.
MADIT-CRT
• 1820 patients, CRT-ICD (1089) vs. ICD (731)
• Inclusion: NYHA 1-2 ischemic or NYHA 2 DCM.
LVEF < 30%,
QRS >130 ms
• Follow-up: 2.4 years
• End point: mortality or HF events
MADIT-CRT result
Conclusion from MADIT-CRT & RAFT
• Extend CRT indication to NYHA Fc II patients.
• In NYHA Fc II, benefit is limit to QRS >150 ms, and LBBB morphology.
• Benefit in NYHA Fc I is not yet concluded.
THANK YOU FOR ATTENTION QUESTION ?