PPM GUIDELINES
INDICATIONS FOR SND

CLASS I
1. Permanent pacemaker implantation is indicated for SND with documented symptomatic bradycardia, including frequent sinus pauses
that produce symptoms. (Level of Evidence: C)

2. Permanent pacemaker implantation is indicated for
symptomatic chronotropic incompetence. (Level of Evidence: C)

3. Permanent pacemaker implantation is indicated for
symptomatic sinus bradycardia that results from required drug therapy for
medical conditions. (Level of Evidence: C)

CLASS IIa
1. Permanent pacemaker implantation is reasonable for SND with heart rate less than 40 bpm without clear association with
significant symptoms
documented. (Level of Evidence: C)

2. Permanent pacemaker implantation is reasonable for
syncope of unexplained origin with SND in EPS. (Level of Evidence: C)

CLASS IIb
1. Permanent pacemaker implantation may be considered in minimally symptomatic patients with chronic heart rate less than 40
bpm while awake
. (Level of Evidence: C)

CLASS III
1. Permanent pacemaker implantation is not indicated for SND in asymptomatic patients. (Level of Evidence: C)
2. Permanent pacemaker implantation is not indicated for SND in patients for whom the symptoms suggestive of bradycardia have been
clearly documented to occur in the absence of bradycardia. (Level of Evidence: C)
3. Permanent pacemaker implantation is not indicated for SND with symptomatic bradycardia due to nonessential drug therapy. (Level of
Evidence: C)



INDICATIONS FOR AVB
CLASS I
1. Permanent pacemaker implantation is indicated for 3rd and advanced 2nd degree AV block at any anatomic level associated
with bradycardia with symptoms
(including heart failure) or ventricular arrhythmias presumed to be due to AV block. (Level of
Evidence: C)

2. Permanent pacemaker implantation is indicated for
3rd degree and advanced 2nd-degree AV block at any anatomic level
associated with arrhythmias and other medical conditions that require drug therapy that results in symptomatic bradycardia.
(Level of Evidence: C)

3. Permanent pacemaker implantation is indicated for
3rd degree and advanced 2nd-degree AV block at any anatomic level in
awake, symptom-free patients in sinus rhythm, with documented periods of asystole greater than or equal to 3.0 seconds or
any escape rate less than 40 bpm, or with an escape rhythm that is below the AV node
. (Level of Evidence: C)

4. Permanent pacemaker implantation is indicated for
3rd degree and advanced 2nd-degree AV block at any anatomic level in
awake, symptom-free patients with AF and bradycardia with 1 or more pauses of at least 5 seconds or longer
. (Level of
Evidence: C)

5. Permanent pacemaker implantation is indicated for 3
rd degree and advanced 2nd-degree AV block at any anatomic level after
catheter ablation of the AV junction
. (Level of Evidence: C)

6. Permanent pacemaker implantation is indicated for 3
rd degree and advanced 2nd-degree AV block at any anatomic level
associated with postoperative AV block that is not expected to resolve
after cardiac surgery. (Level of Evidence: C)

7. Permanent pacemaker implantation is indicated for
3rd degree and advanced 2nd-degree AV block at any anatomic level
associated with neuromuscular diseases with AV block
, such as myotonic muscular dystrophy, Kearns-Sayre syndrome, Erb
dystrophy (limb-girdle muscular dystrophy), and peroneal muscular atrophy, with or without symptoms. (Level of Evidence: B)

8. Permanent pacemaker implantation is indicated for
2nd degree AV block with associated symptomatic bradycardia regardless of
type or site of block
. (Level of Evidence: B)

9. Permanent pacemaker implantation is indicated for
asymptomatic persistent 3rd-degree AV block at any anatomic site with average
awake ventricular rates of 40 bpm or faster
if cardiomegaly
or LV dysfunction is present or if the site of block is below the AV node
. (Level of Evidence: B)

10. Permanent pacemaker implantation is indicated for
2nd or 3rd-degree AV block during exercise in the absence of myocardial
ischemia
. (Level of Evidence: C)


CLASS IIa
1. Permanent pacemaker implantation is reasonable for persistent 3rd-degree AV block with an escape rate greater than 40 bpm
in asymptomatic adult patients without cardiomegaly.
(Level of Evidence: C)

2. Permanent pacemaker implantation is reasonable for
asymptomatic second-degree AV block at intra- or infra-His levels found at
EPS.
(Level of Evidence: B)

3. Permanent pacemaker implantation is reasonable for
1st- or 2nd-degree AV block with symptoms similar to those of pacemaker
syndrome or hemodynamic compromise
. (Level of Evidence: B)

4. Permanent pacemaker implantation is reasonable for
asymptomatic type II 2nd-degree AV block with a narrow QRS. When type II
2nd-degree AV block occurs with a wide QRS, including isolated right bundle-branch block, pacing becomes a Class I recommendation.
(Level of Evidence: B)


CLASS IIb
1. Permanent pacemaker implantation may be considered for neuromuscular diseases such as myotonic muscular dystrophy, Erb
dystrophy (limb-girdle muscular dystrophy), and peroneal
muscular atrophy with any degree of AV block (including 1st-degree AV block), with or without symptoms, because there may be
unpredictable progression of AV conduction disease. (Level of Evidence: B)

2. Permanent pacemaker implantation may be considered for
AV block in the setting of drug use and/or drug toxicity when the block is
expected to recur even after the drug is withdrawn. (Level of Evidence: B)


CLASS III
1. Permanent pacemaker implantation is not indicated for asymptomatic first-degree AV block. (Level of Evidence: B)

2. Permanent pacemaker implantation is not indicated for asymptomatic type I 2nd-degree AV block at the supra-His (AV node) level or
that which is not known to be intra- or infra- Hisian. (Level of Evidence: C)

3. Permanent pacemaker implantation is not indicated for AV block that is expected to resolve and is unlikely to recur (e.g., drug toxicity,
Lyme disease, or transient increases in vagal tone or during hypoxia in sleep apnea syndrome in the absence of symptoms). (Level of
Evidence: B)


INDICATIONS FOR BIFASCICULAR BLOCK
Although 3rd degree AV block is most often preceded by bifascicular block, there is evidence that the rate of progression of bifascicular
block to third-degree AV block is slow

Syncope is common in patients with
bifascicular block. Although syncope may be recurrent, it is not associated with an increased
incidence of sudden death

Although the prevalence of
HV-interval prolongation is high, the incidence of progression to third-degree AV block is low. Because HV
prolongation accompanies advanced cardiac disease and is associated with increased mortality, death is often not sudden or due to AV
block but rather is due to the underlying heart disease itself and nonarrhythmic cardiac causes

EPS: Failure to induce distal block cannot be taken as evidence that the patient will not develop third-degree AV block in the future.
However, if atrial pacing induces nonphysiological
infra-His block, some consider this an indication for pacing. Nevertheless, infra-His
block that occurs during either rapid atrial pacing or programmed stimulation at short coupling intervals may be physiological and not
pathological, simply reflecting disparity between refractoriness of the AV node and His-Purkinje systems.


CLASS I
1. Permanent pacemaker implantation is indicated for advanced 2nd-degree AV block or intermittent 3rd-degree AV block. (Level of
Evidence: B)

2. Permanent pacemaker implantation is indicated for
type II 2nd-degree AV block. (Level of Evidence: B)

3. Permanent pacemaker implantation is indicated for
alternating BBB. (Level of Evidence: C)

CLASS IIa
1. Permanent pacemaker implantation is reasonable for syncope not demonstrated to be due to AV block when other likely causes have
been excluded, specifically ventricular tachycardia (VT). (Level of Evidence: B)

2. Permanent pacemaker implantation is reasonable for an
incidental finding at EPS of a markedly prolonged HV interval (greater
than or equal to 100 milliseconds) in asymptomatic patients. (Level of Evidence: B)

3. Permanent pacemaker implantation is reasonable for an incidental finding at
EPS study of pacing induced infra-His block that is not
physiological. (Level of Evidence: B)

CLASS IIb
1. Permanent pacemaker implantation may be considered in the setting of neuromuscular diseases such as myotonic muscular dystrophy,
Erb dystrophy (limb-girdle muscular dystrophy), and peroneal muscular atrophy with bifascicular block or any fascicular block, with or
without symptoms. (Level of Evidence: C)

CLASS III
1. Permanent pacemaker implantation is not indicated for fascicular block without AV block or symptoms. (Level of Evidence: B)

2. Permanent pacemaker implantation is not indicated for fascicular block with first-degree AV block without symptoms. (Level of Evidence:
B)



INDICATIONS AFTER ACUTE MI

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)

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
EPS may be necessary. (Level of Evidence: B)

3. Permanent ventricular pacing is indicated for persistent and symptomatic second- or third-degree AV block. (Level of Evidence: C)

CLASS IIb
1. Permanent ventricular pacing may be considered for persistent second- or third-degree AV block at the AV node level, even in
the absence of symptoms
. (Level of Evidence: B)

CLASS III
1. Permanent ventricular pacing is not indicated for transient AV block in the absence of intraventricular conduction defects. (Level of
Evidence: B)

2. Permanent ventricular pacing is not indicated for transient AV block in the presence of isolated left anterior fascicular block. (Level of
Evidence: B)

3. Permanent ventricular pacing is not indicated for new BBB or fascicular block in the absence of AV block. (Level of Evidence: B)

4. Permanent ventricular pacing is not indicated for persistent asymptomatic first-degree AV block in the presence of BB or fascicular
block. (Level of Evidence: B)




INDICATIONS FOR HYPERSENSITIVE CAROTID SINUS SYNDROME AND
NEUROCARDIOGENIC SYNCOPE

CLASS I
1. Permanent pacing is indicated for recurrent syncope caused by spontaneously occurring carotid sinus stimulation and carotid sinus
pressure that induces ventricular asystole of more than 3 secs (Level of Evidence: C)

CLASS IIa
1. Permanent pacing is reasonable for syncope without clear, provocative events and with a hypersensitive cardioinhibitory response of 3
seconds or longer. (Level of Evidence: C)

CLASS IIb
1. Permanent pacing may be considered for significantly symptomatic neurocardiogenic syncope associated with bradycardia documented
spontaneously or at the time of tilt-table testing. (Level of Evidence: B)

CLASS III
1. Permanent pacing is not indicated for a hypersensitive cardioinhibitory response to carotid sinus stimulation without symptoms or with
vague symptoms. (Level of Evidence: C)

2. Permanent pacing is not indicated for situational vasovagal syncope in which avoidance behavior is effective and preferred. (Level of
Evidence: C)


INDICATIONS TO PACE TERMINATE ARRHYTHMIAS

CLASS IIa
1. Permanent pacing is reasonable for symptomatic recurrent SVT that is reproducibly terminated by pacing when catheter ablation and/or
drugs fail to control the arrhythmia or produce intolerable side effects. (Level of Evidence: C)

CLASS III
1. Permanent pacing is not indicated in the presence of an accessory pathway that has the capacity for rapid anterograde conduction.
(Level of Evidence: C)


INDICATIONS TO PREVENT TACHYCARDIA

CLASS I
1. Permanent pacing is indicated for sustained pause-dependent VT, with or without QT prolongation. (Level of Evidence: C)

CLASS IIa
1. Permanent pacing is reasonable for high-risk patients with congenital long-QT syndrome. (Level of Evidence: C)

CLASS IIb
1. Permanent pacing may be considered for prevention of symptomatic, drug-refractory, recurrent AF in patients with coexisting SND.
(Level of Evidence: B)

CLASS III
1. Permanent pacing is not indicated for frequent or complex ventricular ectopic activity without sustained VT in the absence of the long-
QT syndrome. (Level of Evidence: C)

2. Permanent pacing is not indicated for the prevention of AF in patients without any other indication for pacemaker implantation.
(Level of Evidence: B)

3. Permanent pacing is not indicated for torsade de pointes VT due to reversible causes. (Level of Evidence: A)

In
MOST, 2,010 patients with SND were randomized between DDDR and VVIR pacing. After a mean follow-up of 33 months, there was a
21% lower risk of AF (p!0.008) in the DDDR group than in the VVIR group.

Dual-site right atrial pacing or alternate single-site atrial pacing from unconventional sites (e.g.,
atrial septum or Bachmann’s bundle) may offer additional benefits to single-site right atrial pacing from the appendage in patients with
symptomatic drug-refractory AF and concomitant bradyarrhythmias; however, results from these studies are also contradictory and
inconclusive.




INDICATIONS FOR CARDIAC TRANSPLANTATION

The incidence of bradyarrhythmias after cardiac transplantation is 8-23%, mostly SND, some associated with sudden death. This could be
temporized with Theophylline, 50% of patients show resolution within 6 to 12 months.

CLASS I
1. Permanent pacing is indicated for persistent inappropriate or symptomatic bradycardia not expected to resolve and for other Class I
indications for permanent pacing. (Level of Evidence: C)

CLASS IIb
1. Permanent pacing may be considered when relative bradycardia is prolonged or recurrent, which limits rehabilitation or discharge after
postoperative recovery from cardiac transplantation. (Level of Evidence: C)

2. Permanent pacing may be considered for syncope after cardiac transplantation even when bradyarrhythmia has not been documented.
(Level of Evidence: C)



INDICATIONS FOR SLEEP APNEA

A small retrospective trial of atrial overdrive pacing in the treatment of sleep apnea demonstrated a decrease “in episodes of central or
obstructive sleep apnea without reducing the total sleep time”. Subsequent randomized clinical trials have not validated a role for atrial
overdrive pacing in
obstructive sleep apnea. Furthermore, nasal continuous positive airway pressure therapy has been shown to be
highly effective for obstructive sleep apnea, whereas atrial overdrive pacing has not.
Central sleep apnea and Cheyne-Stokes sleep-disordered breathing frequently accompany systolic heart failure and are associated with
increased mortality. CRT has been shown to reduce central sleep apnea and increase sleep quality in heart failure patients with ventricular
conduction delay.
INDICATIONS FOR CARDIAC SARCOIDOSIS

Cardiac sarcoidosis usually affects individuals aged 20 to 40 years and is associated with non caseating granulomas with an affinity for
involvement of the AV conduction system. Myocardial involvement occurs in 25% of patients with sarcoidosis, as many as 30% of whom
develop complete heart block. Pacemaker implantation is recommended even if high-grade or complete AV conduction block reverses
transiently.
Cardiac sarcoidosis can also be a cause of life-threatening ventricular arrhythmias with sustained monomorphic VT due to myocardial
involvement. Sudden cardiac arrest may be the initial manifestation of the condition, and patients may have few if any manifestations of
dysfunction in organ systems other than the heart. Although there are no large randomized trials or prospective registries of patients
with cardiac sarcoidosis, the available literature indicates that cardiac sarcoidosis with heart block, ventricular arrhythmias, or LV
dysfunction is associated with a poor prognosis. Therapy with steroids or other immunosuppressant agents may prevent progression of the
cardiac involvement. Bradyarrhythmias warrant pacemaker therapy, but they are not effective in preventing or treating life-threatening
ventricular arrhythmias. Sufficient clinical data are not available to stratify risk of SCD among patients with cardiac sarcoidosis.
Consideration should be given to symptoms such as syncope, heart failure status, LV function, and spontaneous or induced ventricular
arrhythmias at electrophysiological study to make individualized decisions regarding use of the ICD for primary prevention of SCD.

INDICATIONS FOR PREVENTION AND TERMINATION OF ARRHYTHMIAS

Prevention of arrhythmias by pacing has been demonstrated in certain situations. In some patients with long-QT syndrome, recurrent
pause-dependent VT may be prevented by continuous pacing. A combination of pacing and beta blockade has been reported to shorten
the QT interval and help prevent SCD. ICD therapy in combination with overdrive suppression pacing should be considered in high-risk
patients.

CLASS I
1. Permanent pacing is indicated for sustained pause-dependent VT, with or without QT prolongation. (Level of Evidence: C)

CLASS IIa
1. Permanent pacing is reasonable for symptomatic recurrent SVT that is reproducibly terminated by pacing when catheter ablation and/or
drugs fail to control the arrhythmia or produce intolerable side effects. (Level of Evidence: C)

2. Permanent pacing is reasonable for high-risk patients with congenital long-QT syndrome. (Level of Evidence: C)

CLASS IIb
1. Permanent pacing may be considered for prevention of symptomatic, drug-refractory, recurrent AF in patients with coexisting SND.
(Level of Evidence: B)

CLASS III
1. Permanent pacing is not indicated in the presence of an accessory pathway that has the capacity for rapid anterograde conduction.
(Level of Evidence: C)

2. Permanent pacing is not indicated for frequent or complex ventricular ectopic activity without sustained VT in the absence of the long-QT
syndrome. (Level of Evidence: C)

3. Permanent pacing is not indicated for torsade de pointes VT due to reversible causes. (Level of Evidence: A)


Approximately 30% to 60% of atrial tachyarrhythmias may be terminated with atrial ATP in patients who receive pacemakers for
symptomatic bradycardia. Although this has been associated with a reduction in atrial tachyarrhythmia burden over time in selected
patients (195,196), the success of this approach has not been duplicated reliably in randomized clinical trials. In either situation, automatic
atrial therapies should not be activated until the atrial lead is chronically stable, because dislodgement into the ventricle could result in the
induction of VT/VF.


LONG QT SYNDROME
The use of cardiac pacing with beta blockade for prevention of symptoms in patients with the congenital long-QT syndrome is supported by
observational studies. The primary benefit of pacemaker therapy may be in patients with pause-dependent initiation of VT or those with
sinus bradycardia or advanced AV block in association with the congenital long-QT syndrome which is most commonly associated with a Na
channelopathy




RV PACING

DAVID (Dual Chamber and VVI Implantable Defibrillator) trial (580). In this trial, dual-chamber rate-responsive pacing increased HF
admissions and mortality rate as compared to sinus rhythm. A cutoff of approximately
40% right ventricular pacing was seen as
deleterious (581).

Substudy from MADIT-II (Multicenter Automatic Defibrillator Implantation Trial II), patients who were right ventricular paced >50% of the
time had a higher rate of new or worsened HF than those right ventricular paced >50% of the time (582).

Danish study, patients with SND were randomized between AAIR pacing, DDDR pacing with a long AV delay (300 milliseconds), and
DDDR pacing with a short AV delay (less than or equal to 150 milliseconds) (45). The prevalence of ventricular pacing was 17% in the
DDDR– long-AV-delay patients and 90% in the DDDR–short-AV delay patients. At 2.9 years of follow-up, the incidence of
AF was 7.4% in
the AAIR group, 17.5% in the DDDR–long-AV delay group, and 23.3% in the DDDR–short-AV-delay group. There were also
increases in left atrial and LV dimensions seen in both DDDR groups but not the AAIR group. This study supports the superiority of atrial
over dual-chamber pacing and indicates that there may be deleterious effects from even the modest amount of ventricular pacing that
typically occurs with maximally programmed AV delays in the DDD mode.

Also, in the subsequent Danish study comparing atrial with dual-chamber pacing, the incidence of
progression to symptomatic AV
block
, including syncope, was 1.9% per year, even with rigorous screening for risk of AV block at the time of implantation (45).
Programming a dual-chamber device to the conventional DDD mode with a maximally programmable AV delay or with AV search hysteresis
does not eliminate frequent ventricular pacing in a significant fraction of patients (291,292). Accordingly, several pacing algorithms that
avoid ventricular pacing except during periods of high-grade AV block have been introduced recently (293). These new modes dramatically
decrease the prevalence of ventricular pacing in both pacemaker and defibrillator patients (294–296). A recent trial showed the frequency
of RV pacing was 9% with one of these new algorithms compared with 99% with conventional dual-chamber pacing, and this decrease in
RV pacing was associated with a 40% relative reduction in the incidence of persistent AF (296). Additional trials are under way to assess
the clinical benefits of these new pacing modes (297).



INDICATIONS FOR HCM
Early non randomized trials suggested a fall in the LV outflow gradient with dual-chamber pacing and a short AV delay and symptomatic
improvement in some patients but later randomized double-blinded trials failed to demonstrate any QOL improvement with pacing and no
correlation with gradient reduction.
In a small group of patients with symptomatic, HCM with cavity obliteration,
VDD pacing with premature excitation statistically improved
exercise capacity, cardiac reserve and QOL. There are currently no data to support that pacing alters the course of the disease or improve
QOl in HCM. Patients who may benefit the most are those with significant gradients (more than 30 mm Hg at rest or more than 50 mm Hg
provoked). Complete heart block can develop after transcoronary alcohol septal ablation.

CLASS I
1. Permanent pacing is indicated for SND or AV block in patients with HCM as described previously. (Level of Evidence: C)

CLASS IIa
1. Permanent pacing may be considered in medically refractory symptomatic patients with HCM and significant resting or provoked LV
outflow tract obstruction. (Level of Evidence: A) As for Class I indications, when risk factors for SCD are present, consider a DDD
ICD (233,235,237,238,246,247).

CLASS III
1. Permanent pacemaker implantation is not indicated for patients who are asymptomatic or whose symptoms are medically
controlled. (Level of Evidence: C)

2. Permanent pacemaker implantation is not indicated for symptomatic patients without evidence of LV outflow tract obstruction.
(Level of Evidence: C)



Recommendations for Permanent Pacing in Children, Adolescents, and Patients With
Congenital Heart Disease

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)

CLASS IIa
1. Permanent pacemaker implantation is reasonable for patients with congenital heart disease and sinus bradycardia for the prevention
of recurrent episodes of intra-atrial reentrant tachycardia; SND may be intrinsic or secondary to antiarrhythmic treatment. (Level of
Evidence: C) (260,261,264)

2. Permanent pacemaker implantation is reasonable for
congenital third-degree AV block beyond the first year of life with an average
heart rate less than 50 bpm, abrupt pauses in ventricular rate that are 2 or 3 times the basic cycle length, or associated with symptoms due
to chronotropic incompetence. (Level of Evidence: B) (208,270)

3. Permanent pacemaker implantation is reasonable for
sinus bradycardia with complex congenital heart disease with a resting heart
rate less than 40 bpm or
pauses in ventricular rate longer than 3 seconds. (Level of Evidence: C)

4. Permanent pacemaker implantation is reasonable for patients with
congenital heart disease and impaired hemodynamics due to sinus
bradycardia or loss of AV synchrony. (Level of Evidence: C) (250)

5. Permanent pacemaker implantation is reasonable for unexplained
syncope in the patient with prior congenital heart surgery complicated
by transient complete heart block with residual fascicular block after a careful evaluation to exclude other causes of syncope. (Level of
Evidence: B) (273,276–278)

CLASS IIb
1. Permanent pacemaker implantation may be considered for transient postoperative third-degree AV block that reverts to sinus
rhythm
with residual bifascicular block. (Level of Evidence: C) (275)

2. Permanent pacemaker implantation may be considered for
congenital third-degree AV block in asymptomatic children or adolescents
with an acceptable rate, a narrow QRS complex, and normal ventricular function. (Level of Evidence: B) (270,271)

3. Permanent pacemaker implantation may be considered for asymptomatic sinus bradycardia after biventricular repair of congenital heart
disease with a resting heart rate less than 40 bpm or pauses in ventricular rate longer than 3 seconds. (Level of Evidence: C)

CLASS III
1. Permanent pacemaker implantation is not indicated for transient postoperative AV block with return of normal AV conduction
in the otherwise asymptomatic patient. (Level of Evidence: B)(274,275)

2. Permanent pacemaker implantation is not indicated for asymptomatic bifascicular block with or without first-degree AV block
after surgery for congenital heart disease in the absence of prior transient complete AV block. (Level of Evidence: C)

3. Permanent pacemaker implantation is not indicated for asymptomatic type I second-degree AV block. (Level of Evidence: C)

4. Permanent pacemaker implantation is not indicated for asymptomatic sinus bradycardia with the longest relative risk interval
less than 3 seconds and a minimum heart rate more than 40 bpm. (Level of Evidence: C)
MAJOR TRIALS COMPARING AAI/DDD TO VVI

Only the Danish study (281) included a true atrial pacing arm; among patients in the AAI/DDD arm in CTOPP (Canadian Trial of
Physiologic Pacing), only 5.2% had an atrial pacemaker (282).
INDICATIONS FOR PPM FOLLOW-UP

Remote monitoring
Automatic threshold assessment, information regarding capture of the chamber(s) being paced and battery status. TTM may also
provide the caregiver with information regarding appropriate sensing.
Clinic follow-up
usually includes assessment of the clinical status of the patient, battery status, pacing threshold and pulse width, sensing function, and
lead integrity, as well as optimization of sensor-driven rate response and evaluation of recorded events, such as mode switching for AF
detection and surveillance and ventricular tachyarrhythmia events.


Single-chamber pacemakers, twice in the first 6 months after implantation and then once every 12 months
Dual-chamber pacemakers, twice in the first 6 months, then once every 6 months (315).


TTM
Re remote monitoring, The Centers for Medicare and Medicaid Services have not provided regulations regarding the use of this
technology, but have provided limited direction regarding reimbursement. The Centers for Medicare and Medicaid Services have
published a statement that physicians should use the existing current procedural terminology codes for in-office pacemaker and ICD
interrogation codes for remote monitoring of cardiac devices (317).

Goals of TTM nonmagnet ECG assessment are as follows:
• Determine whether the patient displays intrinsic rhythm or is being intermittently or continuously paced at the programmed
settings.
• Characterize the patient’s underlying atrial mechanism, for example, sinus versus AF, atrial tachycardia, etc.
• If intrinsic rhythm is displayed, determine that normal (appropriate) sensing is present for 1 or both chambers depending on whether it
is a single- or dual-chamber pacemaker and programmed pacing mode.

Goals of TTM ECG assessment during magnet application are as follows:
• Verify effective capture of the appropriate chamber(s) depending on whether it is a single- or dual-chamber
pacemaker and verify the programmed pacing mode.
• Assess magnet rate. Once magnet rate is determined, the value should be compared with values obtained on previous transmissions
to determine whether any change has occurred. The person assessing the TTM should also be aware of the magnet rate that
represents elective replacement indicators for that pacemaker.
• If the pacemaker is one in which pulse width is 1 of the elective replacement indicators, the pulse width should also be assessed and
compared with previous values.
• If the pacemaker has some mechanism to allow transtelephonic assessment of threshold (i.e., Threshold Margin Test [TMT™]) and
that function is programmed “on,” the results of this test should be demonstrated and analyzed.
• If a dual-chamber pacemaker is being assessed and magnet application results in a change in AV interval during magnet application,
that change should be demonstrated and verified.
Clinic:

TTM Q 6 months
Clinic visit Q 6 months
Alternating
No survival advantage with pacing. Congenital AVB. Suprahis AVB narrow QRS escape AVB no pace.
AF with pause > 5 sec. Pause > 3 sec. Alternating BBB PG more malignant.
Anterior MI + AVB=> PPM. Inferior MI +AVB=> Observe


With DDD AV synchrony vs VVI one of the trials only showed decreased mortality (DDD vs AAI) while 3 trials showed decreased occurrence
of AF. Only with AF you can VVI