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Pacemaker

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  1. Indications: Permanent pacemaker in AV Block
    1. Class I Indications (helpful)
      1. Sick Sinus Syndrome with symptomatic Bradycardia
      2. Second Degree AV Block with symptomatic Bradycardia
      3. Third Degree AV Block with one associated condition
        1. Symptomatic Bradycardia
        2. Documented Asystole (3 seconds or greater)
        3. Catheter ablation of the AV junction
        4. Neuromuscular disorder with AV Block
          1. Myotonic muscular disorder
          2. Kearns-Sayre Syndrome
          3. Erb's Dystrophy (limb-girdle)
          4. Peroneal muscular atrophy
    2. Class IIa Indications (probably helpful)
      1. Sick Sinus Syndrome with rate <40 bpm
        1. Symptom association with Bradycardia unclear
      2. Asymptomatic third degree AV Block
      3. Asymptomatic Type II second degree AV Block
      4. Asymptomatic Type I AV Block at His level
      5. First degree AV Block and pacemaker syndrome symptoms
    3. Class IIb Indications (Possibly helpful)
      1. Sick Sinus Syndrome with chronic awake rate <30 bpm
        1. Minimally symptomatic patients
      2. Marked First Degree AV Block (>0.3 seconds) with CHF
    4. Class III Indications (Not helpful, possibly harmful)
      1. Asymptomatic Bradycardia due to medication
      2. Asymptomatic First Degree AV Block
      3. Asymptomatic Type I AV Block limited to supra-His
      4. Transient AV Block secondary to resolving condition
        1. Drug toxicity
        2. Lyme Disease
  2. Description: Pacemaker Codes
    1. Position 1 (chamber paced)
      1. V - Ventricle
      2. A - Atrium
      3. D - Dual (A and V)
      4. O - None
    2. Position 2 (chamber sensed)
      1. V - Ventricle
      2. A - Atrium
      3. D - Dual (A and V)
      4. O - None
    3. Position 3 (response to sensing)
      1. V - Triggered
      2. I - Inhibited
      3. D - Dual (T and I)
      4. O - None
    4. Position 4 (programmable functions and rate modulation)
      1. P - Programmable rate and output
      2. M - Muti-programmability of rate, output, sensitivity
      3. C - Communicating via telemetry
      4. R - Rate modulation
      5. O - None
    5. Position 5 (anti-tachyarrhythmia)
      1. P - Pacing (anti-tachyarrhythmia)
      2. S - Shock
      3. D - Dual (P and S)
      4. O - None
  3. Types: Pacemaker Selection for Sinus Node Dysfunction
    1. No signs or future risks for impaired AV conduction
      1. Rate response: Rate-responsive atrial pacer (AAIR)
      2. No rate response: Atrial pacemaker (AAI)
    2. Impaired AV Conduction and no AV synchrony needed
      1. Rate response: Rate-responsive dual chamber (DDDR)
      2. No rate response: Ventricular pacemaker (DDD)
    3. Impaired AV Conduction and AV synchrony needed
      1. Tachyarrhythmia (e.g. PSVT)
        1. Rate response: Rate-responsive dual chamber (DDDR)
        2. No rate response: Dual chamber pacemaker (DDD)
      2. No Tachyarrhythmia
        1. Rate response: Rate-responsive dual and mode switch
        2. No rate response: Dual chamber with mode switching
  4. References
    1. Bernstein (1987) Pacing Clin Electrophysiol 10:794
    2. Gregoratos (1998) J Am Coll Cardiol 31:1175
    3. Gregoratos (2005) Am Fam Physician 71:1563

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