Arrhythmias Update - 08/2021
ESC Guidelines for Pacing & CRT: NEW DEVICES
1. PPM in post TAVR: class I for persisted high-grade AVB or new alternating BBB.
2. HBP: IIa as an alternative to CRT.
3. Leadless PPM: IIa as an alternative to transvenous PPM in those with venous obstruction or pocket issues.
PPM: REVISED INDICATIONS
Timing for Pacemaker: 2021 vs. 2013 Guidelines.
| Conditions | 2021 ESC | 2013 ESC |
| AVB post MI | at least 5d | 2-7d |
| AVB post cardiac Sx | at least 5d | up to 7d |
| SND post cardiac Sx | up to 6wks | 5d to some wks |
| chronotropic incompetence post heart transplant |
> 6wks | "late" in postop period |
| AVB post TAVR | 24-48 hrs | up to 7d |
1. PPM is indicated for syncope + asystolic tilt in patients aged >40.
2. PPM should be considered (IIa) in elderly and frail with syncope bifascicular block.
CRT: REVISED INDICATIONS
1. Benefits of CRT are associated with QRS duration and morphology.
2. Definition of "Optimal Medical Therapy" (OMT) remains debatable.
3. CRT is recommended (IA) in HFrEF (LVEF<40%) with high grade AV block.
4. In "ablate and pace" strategy, CRT is recommended (IB) in HFrEF (LVEF<40%)
Procedural Consideration
Before
the procedure
Imaging Studies
to evaluate structural heart disease (Ic).
to evalute myocardial tissues in patients age <60 (IIa).
Sleep Apnea Syndrome
should be screened in patients with symptoms + bradycardia during sleep.
Genetic Testing
considered in early onset (age <50) of progressive conduction disease.
European Heart Journal, Aug 2021.
DOs & DONTs
during the procedure
Antibiotic
1hr within the skin incision (Ia).
NO Heparin Bridging
in anticoagulated patients.
FEVER
Implantation should be delayed until afbrile of at least 24hrs.
European Heart Journal, Aug 2021.
1. Evaluate for structural heart disease in symptomatic bradycardia.
2. Preop antibiotic is recommended within 1 hr of skin incision.
3. Avoid transvalvular RV lead in mechanical tricuspid valve.
Miscellaneous
1. For a long term need, consider temporary pacemaker using exteriorized active fixation lead.
2. MRI can be performed safely in non-MRI conditional devices as long as a number of precautions are taken.
Mortality Benefit of AV junction ablation & CRT in Permanent AF
AV Junction Ablation + CRT was superior to pharmacological therapy in reducing mortality in patients with permanent AF
and narrow QRS who were hospitalized for HF, irrespective of their baseline EF.
Rhythm Control in AF - 2021 Update
New Update in Rhythm Control
1. Analysis from EAST-AFNET4 showed that the clinical benefit of early, systematic rhythm control
was not different between asymptomatic and symptomatic patients.
2. In patients with AF enrolled in the CABANA trial who
had clinically diagnosed stable heart failure at trial entry, catheter ablation
produced clinically important improvements in survival relative to drug therapy.
Coffee & Alcohol & Arrhythmias
In UK Biobank, a prospective cohort of more than 400,000 subjects,
1. Greater amounts of habitual coffee consumption were inversely associated with a lower risk of arrhythmia.
2. Low levels of alcohol consumption, <7 UK standard drinks or 56g alcohol per wk, were associated with lowest AF risk.
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