2.  Main Reference ◦ ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices): developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons.  Circulation. 2008 May 27;117(21):e350-408.

3.  Complete (3 rd degree AV block) ◦ Complete A V dissociation, regular R waves, Atrium>Ventricle  Second degree AV block ◦ Mobitz I (Wenckebach)  Progressive increase in PR interval before block  Shortening of RR intervals P-P equal (*ventricular phasic dysrhythmia) ◦ Mobitz II  Fixed PR interval before and after block, can be high grade (≥2 non-conducted P waves) or 2:1.  First degree AV block ◦ PR interval >200ms

4.  Third degree or second degree block: ◦ Class 1 indication for pacing if:  Bradycardia associated with symptoms  Need for drug therapy resulting in symptomatic bradycardia  Asymptomatic with pause >3.0s or escape <40bpm or broad complex escape (below level of AV node)  Asymptomatic with AF and pause >5.0secs  Asymptomatic but associated neuromuscular disease  Block occurring during exercise regardless of presence of ischaemia.

5.  Class IIa recommendations ◦ Asymptomatic adults, resting rate >40bpm and without structural heart disease. ◦ Asymptomatic adults with level of block discovered below the AV node at electrophysiological study ◦ Symptoms of pacemaker syndrome ◦ Asymptomatic type II AV block with narrow QRS (note wide QRS makes this class I indication)

6.  Pacing is not indicated or is harmful for the following: ◦ Asymptomatic 1 st degree heart block ◦ Asymptomatic Mobitz type 1 Wenckebach ◦ Transient or unlikely to recur, during episodes of hypoxia in the sleep apnoea syndromes.

7. Unpaced group followed between 1960-1965 before pacing was introduced i.e. Self selected ‘survivors’ From H Sniddon “ Death in Long-term paced patients” Br Heart Journal 1974; 36:1201-1209

8. Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply. Epstein, A. E. et al. J Am Coll Cardiol 2008;51:e1-e62 Selection of Pacemaker Systems for Patients With Atrioventricular Block

9.  Class I (indicated for:) ◦ Documented symptomatic bradycardia including frequent sinus pauses ◦ Chronotropic incompetence ◦ Essential concomitant use of rate slowing drugs  Class IIa (Reasonable in:) ◦ Symptoms not documented but resting HR<40bpm ◦ Unexplained syncope and abnormal EP study  Class IIb (“may be considered in”:) ◦ Asymptomatic and resting HR ≤ 40bpm

10. Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply. Epstein, A. E. et al. J Am Coll Cardiol 2008;51:e1-e62 Selection of Pacemaker Systems for Patients With Sinus Node Dysfunction

11. HR Anderson et al. Lancet. 1997; 9086: 1210-1216 Overall Survival Survival CVS death Freedom from AF Freedom from Chronic AF

12. Rosenqvist et al. Am Heart J; 1988;116: 16-22 Retrospective study of 168 patients AF significantly greater in VVI group c.f. AAI group 47% vs 6.7% Mortality VVI=23% AAI=8% (p=0.045)

13. Lamas et al. NEJM 2002; 346: 1854 RCT of 2010 pts with SSS 1014 DDD 996 VVI AF developed in: VVI 27.1% DDD 21.4% (p=0.004) Note still high rate of AF with V pacing in either arm

14. Sweeny et al. NEJM. 2007; 357: 1000-8 Comparison of minimal ventricular pacing (MVP) and conventional DDD. RCT of 1065 patients MVP 530 DDD 535 Primary endpoint time to Afib (trial stopped early as endpoint met) AF MVP: 7.9% DDD: 12.7% (p=0.004) HR 0.6 (0.41-0.88)

15.  Ventricular pacing in SSS is bad! ◦ Increased risk of death ◦ Increased risk of stroke ◦ Increased risk of AF  DDD pacing is better ◦ No difference in Mortality ◦ Increased risk of AF but better than VVI  Atrial based pacing is best! DANPACE * DDD vs AAI

16.  Class I ◦ Syncope with clear carotid events and CSM producing pause >3 secs  Class IIa ◦ Syncope with CSM >3secs  Class IIb ◦ ‘Significantly’ symptomatic neurocardiogenic syncope associated with documented bradycardia spontaneously or at Tilt table  Class III (Not-indicated) ◦ Positive CSM in absence of symptoms Situational vasovagal syncope

17.  102 patients followed for 7-30 years  Stokes-Adams attacks in 27; fatal in 8 ◦ First attack fatal in 6/8 ◦ 19 survived and paced ◦ Long QTc (>0.45s) observed in 7 – all 7 had subsequent SA attack. All 7 had previously normal QTc. 3 died, 4 paced survived.  Ventricular rate gradually decreased with age  Mitral regurgitation developed in 16 (4 died)  A PPM reduced the risk of death Michaelsson et al. Circulation 1995;92:442-9

18. CLASS I 1. Permanent pacemaker implantation is indicated for advanced second- or third-degree AV block associated with symptomatic bradycardia, ventricular dysfunction, or low cardiac output. (Level of Evidence: C) 2. Permanent pacemaker implantation is indicated for SND with correlation of symptoms during age-inappropriate bradycardia. The definition of bradycardia varies with the patient’s age and expected heart rate. (Level of Evidence: B) (53,86,253,257) 3. Permanent pacemaker implantation is indicated for postoperative advanced second- or third-degree AV block that is not expected to resolve or that persists at least 7 days after cardiac surgery. (Level of Evidence: B) (74,209) 4. Permanent pacemaker implantation is indicated for congenital third-degree AV block with a wide QRS escape rhythm, complex ventricular ectopy, or ventricular dysfunction. (Level of Evidence: B) (271–273) 5. Permanent pacemaker implantation is indicated for congenital third-degree AV block in the infant with a ventricular rate less than 55 bpm or with congenital heart disease and a ventricular rate less than 70 bpm. (Level of Evidence: C) (267,268) Recommendations for Permanent Pacing in Children, Adolescents, and Patients With Congenital Heart Disease

19. Pacing for Atrioventricular Block Associated With Acute Myocardial Infarction CLASS I 1. Permanent ventricular pacing is indicated 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 ST-segment elevation MI. (Level of Evidence: B) (79,126–129,131) 2. Permanent ventricular pacing is indicated for transient advanced second- or third-degree infranodal AV block and associated bundle-branch block. If the site of block is uncertain, an electrophysiological study may be necessary. (Level of Evidence: B) (126,127) 3. Permanent ventricular pacing is indicated for persistent and symptomatic second- or third-degree AV block. (Level of Evidence: C)

20. Recommendations for Cardiac Resynchronization Therapy in Patients With Severe Systolic Heart Failure CLASS I 1. For patients who have LVEF less than or equal to 35%, a QRS duration greater than or equal to 0.12 seconds, and sinus rhythm, CRT with or without an ICD is indicated for the treatment of NYHA functional Class III or ambulatory Class IV heart failure symptoms with optimal recommended medical therapy. (Level of Evidence: A) (222,224,225,231)

21. IPG Right Atrial Lead Implantable Pulse generator (CAN) Right Ventricular Lead Left Ventricular Lead

22. Unipolar Large Spike on ECG Bipolar Small Spike on ECG  Circuit between Lead tip and IPG  Circuit between two poles at the end of the lead IPG

29. Septal and ApicalApical

30. RV Outflow SeptumApical

33.  72 year old female attends ER with episode of syncope. No prodrome.  Telemetry recording as below  What does the Trace show?  What is the optimum treatment

34.  65 male admitted with seizures.

36.  Asymptomatic 54 year old male

37.  24 post op