Permanent pacemakers

Long-term management of patients with sick sinus syndrome I requires implantation of a permanent pacemaker.12... 

Symptomatic carotid sinus hypersensitivity also should be treated with permanent pacemaker therapy. Patients who remain symptomatic may benefit from adding an a-adrenergic stimulant such as midodrine. 

Chronic symptomatic AV block warrants insertion of a permanent pacemaker. Patients without symptoms can sometimes be followed closely without the need for a pacemaker. 

Effects on pacemaker thresholds Flecainide increases endocardial pacing thresholds and may suppress ventricular escape rhythms. These effects are reversible. Use with caution in patients with permanent pacemakers or temporary... 

Patients with decompensated cardiac failure requiring the use of IV inotropic therapy (such patients should first be weaned from IV therapy before initiating carvedilol) bronchial asthma (see Warninas) or related bronchospastic conditions second- or third-degree AV block sick sinus syndrome or severe bradycardia (unless a permanent pacemaker is in place) cardiogenic shock clinically manifest hepatic impairment hypersensitivity to the drug. 

A decision to refer for permanent pacemaker implantation for loss of atrioventricular synchrony due to first degree AV nodal block is challenging. In the setting of normal conduction in the ventricles, the improvement that may be gained by improving atrioventricular synchrony must be weighed against... 

Hindman MC, Wagner GS, JaRo M, et al. The clinical significance of bundle branch block complicating acute myocardial infarction. 2. Indications for temporary and permanent pacemaker insertion. Circulation... 

Saxon LA, Stevenson WG, Middlekauff HR, Stevenson LW. Increased risk of progressive hemodynamic deterioration in advanced heart failure patients requiring permanent pacemakers. Am. Heart J. 1993 125 1306-10. 

Manolis AG, Katsivas AG, Lazaris EE, Vassilopoulos CV, Louvros NE. Ventricular performance and quality of life in patients who underwent radiofrequency AV junction ablation and permanent pacemaker implantation due to medically refractory atrial tachyarrhythmias. J. Interv. Card. Electrophysiol. 1998 2 71-6. 

Bradyarrhythmias (including asystole) and/or hypotension are frequent in CS, usually occur during balloon inflations and generally respond promptly to balloon deflation. Prevention is by adequate hydration, conservative balloon sizing, premedication with atropine and early ambulation. Although some advocate the routine prophylactic use of temporary transvenous pacemakers in CS (64,65), we consider the risks of this procedure to outweigh any potential benefit. In one series (n = I 14), a transvenous pacemaker was required in 9.6% (66), though in our experience this is needed far less frequently, Permanent pacemaker requirement is exceptionally rare, Occasionally, patients require short-term treatment... 

Following septal ablation, patients should be monitored in a coronary care unit for 24 to 48 hours and the temporary pacing wire should be removed at the end of this period in the absence of atrioventricular block. Patients may then be transferred to a telemetry unit for monitoring of arrhythmias. Total hospitalization is usually for three to five days to monitor for occurrence of complete heart block that would require a permanent pacemaker. A sizeable infarction is induced with alcohol ablation and causes creatinine phosphokinase to peak at 1000 to 1500 one day after the ablation. Patients should be maintained on aspirin indefinitely. 

Septal ablation related mortality at experienced centers is currently 1% to 2%, similar to that of surgical myectomy (Table 4). Conduction system abnormalities are relatively common complications of septal ablation, Permanent right bundle branch block occurs in about 50% of patients and transitory complete heart block in 60% and permanent pacemakers required for high grade atrioventricular block in about 5% to 20%, Concerns of late occurrence of complete heart block following septal ablation mandates in-patient monitoring for 4 to 5 days,... 

A 65-year-old man taking lithium for 2 years, with therapeutic concentrations, developed sinus bradycardia (30 beats/minute), which remitted when the drug was stopped and recurred when it was restarted (128). Implantation of a permanent pacemaker allowed lithium to be continued. 

Acute sinus bradycardia requires treatment if it is symptomatic e.g. where there is hypotension or escape rhythms extreme bradycardia may allow a ventricular focus to take over and lead to ventricular tachycardia. The foot of the bed should be raised to assist venous return and atropine should be given i.v. Chronic symptomatic bradycardia is an indication for the insertion of a permanent pacemaker. 

The use of permanent pacemakers is beyond the scope of this book. In an emergency, AV conduction may be improved by atropine (antimuscarinic vagal block) (0.6 mg i.v.) or by isoprenaline (p-adrenoceptor agonist) (0.5-10 micrograms/min, i.v.). Temporary pacing wires may be needed prior to referral for pacemaker implantation. 

A 64-year-old woman with systemic lupus erythematosus took chloroquine for 7 years (cumulative dose 1000 g). She developed sjmcope, and the electrocardiogram showed complete heart block a permanent pacemaker was inserted. The next year she presented with biventricular cardiac failure, skin hyperpigmentation, proximal muscle weakness, and chloroquine retinopathy. Coronary angiography was normal. An echocardiogram showed a restrictive cardiomyopathy. A skeletal muscle biopsy was characteristic of chloroquine myopathy. Chloroquine was withdrawn and she improved rapidly with diuretic therapy. 

An 81-year-old woman, who had a permanent pacemaker for complete heart block with symptomatic bradycardia-dependent torsade de pointes, had breakthrough torsade de pointes during therapy with cisapride 10 mg tds for 22 days and paroxetine for 9 days (11). She made a good recovery on withdrawal of the drugs. 

The adverse effects associated with the use of verapamil include constipation, sinus node blockade, prolongation of the PR interval, AV dissociation, hypotension, and pulmonary congestion." The risks may outweigh the benefits in patients with (1) a markedly elevated pulmonary capillary wedge pressure or pulmonary artery occlusion pressure, (2) a history of paroxysmal nocturnal dyspnea or orthopnea, (3) sick sinus syndrome or significant AV nodal disease in the absence of a permanent pacemaker, (4) low systolic blood pressure, and (5) a substantial outflow gradient.Verapamil should be avoided inpatients with heart failure owing to systolic dysfunction. There is no evidence that either /3-blockade or verapamil protects the patient from sudden cardiac death. 

An elderly man with long standing brady-tachycardia was successfully treated for atrial flutter firstly with a temporary pacemaker (later withdrawn) and 600 mg amiodarone daily. Ten days later, and 25 minutes after a permanent pacemaker was inserted under local anaesthesia with 15 mL of 2% lidocaine, severe sinus bradycardia and long sinoatrial arrest developed. He was effectively treated with atropine plus isoprenaline, and cardiac massage. ... 

The decision to implant a permanent pacemaker usually is based on the major goals of symptom relief (at rest and with physical activity), restoration of functional capacity and quality of life, and reduced mortality. As with other healthcare technologies, the appropriate use of pacing is the intent of indications guidelines published by professional societies in cardiology. (The most recent version of guidelines for the United States can be found on the website of the Heart Rhythm Society.)... 

Holmes DR Jr (1986) Permanent pacemaker implantation. In Furman S, Hayes DL, Holmes DR Jr (eds) A practice of cardiac pacing. Futura, Mount Kisco, pp 97-127... 

Ellestad MH, French J (1989) Iliac vein approach to permanent pacemaker implantation. Pacing Clin Electrophysiol 12(7 Ptl) 1030-1033... 

Byrd CL, Schwartz SJ, Hedin N (1991) Intravascular techniques for extraction of permanent pacemaker leads. J Tho-rac Cardiovasc Surg 101(6) 989-997... 

Uslan DZ, Sohail MR, St Sauver JL et al (2(X)7) Permanent pacemaker and implantable cardioverter defibrillator infec-tion a population-based study. Arch Intern Med 167 669-675... 

Sohail MR, Uslan DZ, Khan AH et al (2007) Risk factor analysis of permanent pacemaker infection. Clin Infect Dis 45 166-173... 

Urslan DZ, Sohail MR, Friedman PA et al (2006) Frequency of permanent pacemaker or implantable cardioverter-defibrillator infection in patients with gram-negative bacteremia. Clin Infect Dis 43 731-736... 

Da Costa A, Kirkorian G, Cucherat M et al (1998) Antibiotic prophylaxis for permanent pacemaker implantation a meta-analysis. Circulation 97 1796-1801... 

Chamis AL, Peterson GE, Cabell CH et al (2001) Staphylococcus aureus bacteremia in patients with permanent pacemakers or implantable cardioverter-defibrillator. Circulation 104 1029-1033... 

Byrd CL, Wilkoff BL, Love CJ et al (1999) Intravascular extraction of problematic or infected permanent pacemaker leads 1994-1996. U.S. Extraction Database, MED Institute. Pacing Clin Electrophysiol 22 1348-1357... 

Kawanishi DT, Brinker JA, Reeves R et al (1998) Kaplan-Meier analysis of freedom from extraction or death in patients with an Accufix J retention wire atrial permanent pacemaker lead a potential management tool. Pacing Clin Electrophysiol 21 2318-2321... 

Goto Y, Aabe T, Sekine S et al (1998) Long-term thrombosis after transvenous permanent pacemaker implantation. Pacing Clin Electrophysiol 21 1192- 1195... 

Kennergren C (1999) Excimer laser assisted extraction of permanent pacemaker and ICD leads present experiences of a European multi-centre study. Eur J Cardiothorac Surg 15(6) 856-860... 

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