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 ?