Guidelines for the pacemaker insertion

 There are 3 types of artificial pacemakers:

• Implantable pulse generators with endocardial or myocardial electrodes
• External, miniaturized, patient portable, battery-powered, pulse generators with exteriorized electrodes for temporary transvenous endocardial or transthoracic myocardial pacing
• Console battery or AC-powered cardioverters or monitors with high-current external transcutaneous or low-current endocardial or myocardial circuits for temporary pacing in asynchronous or demand modes, with manual or triggered initiation of pacing

Following conditions are included in the ACC/AHA/HRS guidelines for the pacemaker insertion

• Sinus Node Dysfunction

1. Documented symptomatic sinus bradycardia including frequent sinus pauses which produce symptoms and symptomatic sinus bradycardia that results from required drug therapy for medical condition
2. Symptomatic chronotropic incompetence (failure to achieve 85% of age-predicted maximal heart rate during formal or informal stress test or inability to mount age appropriate heart rate during activities of daily living)

• Acquired Atrioventricular (AV) Block

1. Complete third-degree AV block with or without symptoms.
2. Symptomatic second degree AV block, Mobitz type I and II
3. Exercise-induced second or third degree AV block in the absence of myocardial infarction
4. Mobitz II with widened QRS complex

• Chronic Bifascicular Block

1. Advanced second-degree AV block or intermittent third-degree AV block
2. Alternating bundle-branch block
3. Type II second-degree AV block.

• After Acute Phase of Myocardial Infarction

1. Permanent ventricular pacing for persistent second degree AV block in the His-Purkinje system with alternating bundle branch block or third degree AV block within or below the His-Purkinje system after the ST-segment elevation MI (STEMI)
2. Permanent ventricular pacing for a transient advanced second or third-degree infranodal AV block and associated bundle branch block
3. Permanent ventricular pacing for persistent and symptomatic second or third degree AV block

• Neurocardiogenic Syncope and Hypersensitive Carotid Sinus Syndrome

1. Recurrent syncope caused by spontaneously occurring carotid sinus stimulation and carotid sinus pressure that induces ventricular asystole of more than 3 seconds

• Post Cardiac Transplantation

1. For persistent inappropriate or symptomatic bradycardia not expected to resolve and for other class I indications of permanent pacing.

• Hypertrophic Cardiomyopathy (HCM)

1. Patients with HCM having Sinus node dysfunction and AV block

• Pacing to Prevent Tachycardia

1. For sustained pause dependent VT, with or without QT prolongation

• Cardiac Resynchronization Therapy (CRT) in Patients with Severe Systolic Heart Failure

1. Patients with left ventricular ejection fraction (LVEF) of less than or equal to 35%, sinus rhythm, LBBB (left bundle branch block), New York Heart Association (NYHA) Class II, III or IV symptoms while on optimal medical therapy with a QRS duration of greater than or equal to 150 ms, CRT with or without ICD is indicated

• Congenital Heart Disease

1. For advanced second or third-degree AV block associated with symptomatic bradycardia, ventricular dysfunction, or low cardiac output; also for advanced second or third-degree AV block which is not expected to resolve or persists for 7 days or longer after cardiac surgery
2. For sinus node dysfunction with a correlation of symptoms during age inappropriate bradycardia
3. Congenital third-degree AV block with a wide QRS escape rhythm, complex ventricular ectopy or ventricular dysfunction
4. Congenital third-degree AV block in an infant with a ventricular rate of less than or equal to 55 bpm or with congenital heart disease with a ventricular rate of less than or equal to 70 bpm