1. 2013 THRS Allied Professional Education Program
Cardiovascular Implantable Electronic Device (CIED)
心臟植入性電子儀器之適應症
(Indications for CIED)
高雄榮民總醫院心臟內科
江承鴻 醫師
2013.10.19 (Sat)
1

2. DBT Guideline
2012 ACCF/AHA/HRS Focused Update
Incorporated Into the 2008 Guidelines for
Device-Based Therapy of Cardiac Rhythm
Abnormalities
Developed in Collaboration With the American Association
for Thoracic Surgery, Heart Failure Society of America, and
Society of Thoracic Surgeons

3. Recommendations & Level of
Evidence
Class I
Class IIa
Class IIb
Class III
Benefit >>> Risk
Benefit >> Risk
Additional studies with
focused objectives
needed
Benefit ≥ Risk
Additional studies with
broad objectives
needed; Additional
registry data would be
helpful
Risk ≥ Benefit
No additional studies
needed
Procedure/
Treatment SHOULD
be performed/
administered
IT IS REASONABLE to
perform
procedure/administer
treatment
Procedure/Treatment
MAY BE CONSIDERED
Procedure/Treatment
should NOT be
performed/administered
SINCE IT IS NOT
HELPFUL AND MAY
BE HARMFUL
Level of Evidence:
Level A:
Data derived from multiple randomized clinical trials or meta-analyses
Multiple populations evaluated;
Level B:
Data derived from a single randomized trial or nonrandomized studies
Limited populations evaluated
Level C:
Only consensus of experts opinion, case studies, or standard of care
Very limited populations evaluated
3

4. Indications
for pacing
4

5. Symptomatology + = Reliable Indications
Documented Events
for Pacing
ECG documentation in the medical record is essential !
5

6. Indications For Pacing
•
•
•
•
Sick Sinus Syndrome
Heart Block
Chronic Bifascicular Block
Carotid Sinus Hypersensitivity
& Neurocardiogenic Syncope
• HOCM, DCM
6

7. Sinus Node Dysfunction
(Sick Sinus Syndrome)
•
•
•
•
Sinus Bradycardia
Sinus Arrest
SA Exit Block
Bradycardia-Tachycardia
Syndrome
• Symptomatic chronotropic
incompetence
7

8. Sinus Node Dysfunction
• Class I
– SND with symptomatic bradycardia,
including frequent sinus pauses that
produce symptoms (c)
– Symptomatic chronotropic
incompetence (c)
– Symptomatic sinus bradycardia from
required drug therapy (c)
8

9. Sinus Node Dysfunction
• Class IIa
– SND with HR < 40 BPM but the
symptoms and bradycardia has not been
documented (c)
– Syncope of unexplained origin when SND
is discovered in EP study (c)
• Class IIb
– Minimal symptoms with chronic HR < 40
BPM while awake (c)
9

10. Sinus Node Dysfunction
• Class III
– Without symptoms (c)
– Symptoms unrelated to bradycardia
(c)
– Symptomatic sinus bradycardia due to
nonessential medications (c)
10

11. Sinus Node Dysfunction Sinus Bradycardia
Inappropriate marked sinus bradycardia
• Patient case:
• Elderly gentleman denied symptoms.
• Family reported that he napped frequently,
would fall asleep at the kitchen table during a
meal and often fell asleep when friends were
visiting.
• Patient was proud of his “athletic heart”,
particularly as he never exercised.

12. Sinus Node Dysfunction
Holter monitor
Single APB with marked overdrive suppression
of sinus node, mild sinus bradycardia

13. Sinus Node Dysfunction Brady-Tachy Syndrome
Marked sinus node suppression post-spontaneous
termination of AFib, predisposes to APBs which triggers
next episode of PAF

14. Selection of Pacemaker for Sinus Node Dysfunction
Sinus Node Dysfunction
Evidence for impaired AV conduction or concern over
future development of AV block
No
Yes
Desire for
rate
response
No
AAI
Desire for AV
synchrony
No
Yes
AAIR
Yes
Desire for
rate
response
Desire for
rate
response
No
VVI
Epstein A, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of
Cardiac Rhythm Abnormalities. J Am Coll Cardiol 2008; 51:e1–62. Figure 2.
Yes
VVIR
No
DDD
Yes
DDDR
14

15. AV Block
• First degree
• Second degree
- Wenckebach
- Mobitz II
- 2:1 (high grade)
• Third degree
- Chronic stable
- Asystole
15

16. AV Block
• Class I
– 3rd & advanced 2nd degree AV block at any level
- Bradycardia with symptoms or ventricular
arrhythmia due to AV block (c)
- Drug therapy results in symptomatic
bradycardia (c)
- Awake, symptom-free, asystole > 3.0
seconds or escape rate< 40 BPM (c)
- Awake, symptom-free, AF with pauses ≧ 5
seconds (c)
- Post-AV ablation or post heart surgery (c)
- Neuromuscular disease (b)
– 2nd degree AV block if symptomatic and not
reversible (b)
16

17. AV Block
• Class IIa
–“Asymptomatic” 3rd degree AV block of HR >
40 BPM (c)
–“Asymptomatic” 2nd degree AV block at intraHis or infra-His levels at EP study (b)
–1st degree or 2nd degree AV block with
symptoms (b)
–“Asymptomatic” Mobitz II 2nd degree AV
block (b)
17

18. AV Block
• Class IIb
– Neuromuscular disease, with or without
symptoms, as the progression is
unpredictable (b)
– AV block due to medications or drug
toxicity, expected to recur even after drug
withdrawn (b)
18

19. AV Block
• Class III
– Asymptomatic 1st degree AV Block (b)
– Asymptomatic Mobitz I 2nd degree AV
block at supra-His (AV node) level (c)
– AV block due to reversible etiology
(b)
- Lyme’s disease
- Acute inferior wall MI
- Drug effect or toxicity
19

20. AV Block - First Degree AV
Block
•Significant FIRST degree AV Block (PR 400 ms+) will
predispose to late diastolic regurgitation, compromised
hemodynamics and induce pseudo pacemaker syndrome

21. AV Block - First Degree AV
Block
A
AV
V
First degree AV Block that induces symptoms c/w
pacemaker syndrome (functional retrograde conduction)

22. AV Block - 2nd Degree Wenckebach
• Progressive increase in PR interval until a P wave is
not conducted
• Pause terminated by shortened PR interval

23. AV Block - Mobitz II
• No change in PR interval preceding or following
blocked P wave
• Wide QRS (tri fascicular conduction system disease)

24. AV Block - 2nd Degree
Mobitz II
Mobitz II 2nd AV Block may be associated with
abrupt asystolic complete heart block without a
stable escape focus

25. AV Block - 2:1(High
Grade) 2nd Degree AVB
Narrow QRS - block in AV node (or Bundle of His)
Wide QRS - cannot identify level of block

26. 2:1 AV Block
Mechanism based on preceding or
following rhythms
Lead II
Lead V1

27. AV Block
Chronic Stable Complete Heart Block
•75-year-old man referred for “slow pulse”. Denies
syncope, presyncope. BUT lacks energy which he
attributed to his age!
In the presence of a normal sinus node, use the atrial
rate as an indicator of the degree of physiologic stress.

28. AV Block
Complete in presence of A Fib

29. AV Block
Not Always Obvious
• What is this rhythm?
• Sinus bradycardia
• First degree AV Block

30. AV Block
Not Always Obvious
Baseline
Post-Atropine
Sinus rate accelerates, unmasks complete heart block,
ventricular rate does NOT change, hence top tracing was sinus
brady with isorhythmic AV dissociation and CHB

31. Selection of Pacemaker for Atrioventricular Block
AV block
Chronic atrial
tachyarrhythmia,
reversion to sinus
rhythm not anticipated
No
Desire for
AV
synchrony
No
Yes
Desire for
rate
response
No
Yes
Yes
VVI
Desire for
atrial pacing
Desire for
rate
response
No
VVIR
No
Yes
Yes
VDD
VVI
VVIR
Desire for
rate
response
No
Epstein A, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of
Cardiac Rhythm Abnormalities. J Am Coll Cardiol 2008; 51:e1–62. Figure 1.
DDD
Yes
DDDR
31

32. Neurally Mediated
Syndromes
• Hypersensitive
carotid sinus
syndrome
• Malignant
vasovagal syncope
(neurocardiogenic
syncope)
32

33. Neurally Mediated
Syndromes
• Carotid Sinus Massage
(CSM)
•
•
•
•
Check for bruits
Always monitor ECG
One side at a time
Gentle
33

34. Neurally Mediated
Syndromes
• Class I
– Recurrent syncope, CSM > 3 seconds of
asystole without vagomimetic medications (c)
• Class IIa
– Recurrent syncope without clear and provocative
cause, CSM > 3 seconds of asystole (c)
• Class IIb
– Recurrent syncope, tilt table test with marked
bradycardia (b)
34

35. Neurocardiogenic Syncope
Cardioinhibitory
• Tilttest

36. Indications for
Cardiac
Resynchronization
(CRT) Therapy
Right Atrial
Lead
Left Ventricular
Lead
Right Ventricular
Lead
36

37. CRT in Systolic Heart Failure
• Class I
- LVEF ≦ 35%, sinus rhythm, LBBB with QRS
≧ 150 ms, and NYHA II, III, or ambulatory IV
[(a) for NYHA III/IV; (b) for NYHA II].
• Class IIa
- LVEF ≦ 35%, sinus rhythm, LBBB with QRS
120 ~ 149 ms, and NYHA II, III, or
ambulatory IV (b)
- LVEF ≦ 35%, sinus rhythm, non-LBBB with
QRS ≧ 150 ms, and NYHA II, III, or
ambulatory IV
37

38. CRT in Systolic Heart Failure
• Class IIa
- AF and LVEF ≦ 35% if a) require ventricular
pacing or meet CRT criteria and b) AV nodal
ablation or pharmacologic rate control will
allow near 100% ventricular pacing with CRT
(b)
- Patients with LVEF ≦ 35% and undergoing
new or replacement device placement with
requirement for significant (>40%)
ventricular pacing (c)
38

39. CRT in Systolic Heart Failure
• Class IIb
- LVEF ≦ 30%, ischemic heart failure, sinus rhythm,
LBBB QRS with ≧150 ms, & NYHA I.
- LVEF ≦ 35%, sinus rhythm, non-LBBB QRS with 120
~ 149 ms, and NYHA III/ambulatory class IV (b)
- LVEF ≦ 35%, sinus rhythm, non-LBBB QRS with ≧
150 ms, and NYHA II (b)
• Class III
- NYHA I/II, non-LBBB QRS with <150ms (b)
- Comorbidities and/or frailty limit survival with
good functional capacity <1 year (c)
39

40. Indications for CRT
cardiomyopathy on GDMT for >3 mo or on GDMT and >40 d after MI,
or with implantation of pacing or defibrillation device for special indications
LVEF <35%
Evaluate general health status
Comorbidities and/or frailty limit survival
with good functional capacity to <1 y
Continue GDMT without
implanted device
Acceptable noncardiac health
Evaluate NYHA clinical status
NYHA class I symptoms
NYHA class II, III, and ambulatory class IV symptoms
Class I
LBBB pattern, sinus rhythm, QRS duration ≥150 ms
Class IIa
LBBB pattern, QRS 120-149 ms
OR
Non-LBBB pattern, QRS >150 ms
OR
Class IIb
•LVEF <30%
•QRS >150 ms
•LBBB pattern
•Ischemic
cardiomyopathy
Anticipated to require frequent ventricular pacing (>40%)
OR
Atrial fibrillation, if ventricular pacing is required or QRS criteria above are met
and rate control will result in near 100% ventricular pacing with CRT
Class IIb
Non-LBBB pattern, QRS 120-149 ms
NYHA class IV (stage D)
Refractory symptoms or
dependence on intravenous
inotropes
Device not indicated except
in selected patients listed for
transplantation or with LV
assist devices
If device already in place,
consider deactivation of
defibrillation

41. 心房同步 雙心室節律器 (CRT)
中央健康保險局適應症
98.7.1. 修訂
( 一 ) 應事先審查。
( 二 ) 正常竇房節心律， LVEF≦35% 且
CLBBB(QRS 寬度≧ 0.12sec) ，且 NYHA
Functional Class III, IV 及經適當藥物治療仍不能
改善之病患。
( 三 ) 心房顫動之病患， LVEF≦35% 且
CLBBB(QRS 寬度≧ 0.12sec) ，且 NYHA
Functional Class III, IV 及經適當藥物治療仍不能
改善之病患。
( 四 ) 心室節律器依賴之病
患， LVEF≦35% ， NYHA Functional Class III,
IV 及經適當藥物治療仍不能改善者。

42. Indications
for
Implantable
CardioverterDefibrillators
(ICD) Therapy
42

43. ICD (Secondary Prevention)
• Class I
- Survivors of cardiac arrest due to VF or
hemodynamically unstable sustained VT after
exclude reversible causes (a)
- Structural heart disease & spontaneous
sustained VT, whether hemodynamically
stable or unstable (b)
- Syncope of undetermined origin with
hemodynamically significant sustained VT or
VF induced at EP study (b).
43

44. ICD (Primary Prevention)
• Class I
- LVEF ≦ 35% due to prior MI, ≧40 days postMI, NYHA II/III (a)
- Non-ischemic DCM, LVEF ≦ 35%, NYHA
II/III (b)
- LVEF < 30% due to prior MI, ≧ 40 days postMI, NYHA I (a)
- Non-sustained VT due to prior MI, LVEF ≦
40%, inducible VF/sustained VT at EP
study (b)
44

45. ICD
• Class IIa
- Unexplained syncope, significant LV
dysfunction, non-ischemic DCM (c)
- Sustained VT and normal or near-normal
ventricular function (c)
- HCM & Arrhythmogenic right ventricular
dysplasia/cardiomyopathy (ARVD/C) with 1
or more major risk factors for SCD (c)
- Long-QT syndrome with syncope and/or
VT while receiving beta blockers (b)
45

46. ICD
• Class IIa
- Non-hospitalized patients awaiting
transplantation (c)
- Brugada syndrome with syncope (c)
- Brugada syndrome with documented VT that
has not resulted in cardiac arrest (c)
- Catecholaminergic polymorphic VT with
syncope and/or documented sustained VT while
receiving beta blockers (c)
- Cardiac sarcoidosis, giant cell myocarditis, or
Chagas disease (c)
46

47. ICD
• Class IIb
- Non-ischemic heart disease with LVEF ≦
35%, NYHA I (c)
- Long-QT syndrome and risk factors for SCD
(b)
- Syncope and advanced structural heart
disease, failed to define a cause (c)
- Familial cardiomyopathy associated with
sudden death (c)
- LV non-compaction (c)
47

48. ICD
• Class III
- Do not have a reasonable expectation of
survival with an acceptable functional status
for at least 1 year (c)
- Incessant VT or VF (c)
- Psychiatric illnesses that may be
aggravated by device implantation or that
may preclude systematic follow-up (c)
- NYHA IV with drug-refractory CHF, not
candidates for cardiac transplantation or
CRT-D (c)
48

49. ICD
• Class III
- Syncope of undetermined cause, without inducible
ventricular tachyarrhythmias, without structural
heart disease (c)
- VF / VT is amenable to surgical or catheter
ablation (e.g., atrial arrhythmias associated with the
WPW syndrome, RV or LV outflow tract VT, idiopathic
VT, or fascicular VT in the absence of structural heart
disease) (c)
- Ventricular tachyarrhythmias due to a completely
reversible disorder, without structural heart disease
(e.g., electrolyte imbalance, drugs, or trauma) (b)
49

50. Thanks
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