From the Guidelines
Permanent pacemaker (PPM) implantation is indicated for patients with symptomatic bradycardia, high-grade atrioventricular (AV) block, or specific conditions that impair the heart's electrical conduction system, as stated in the 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay 1. The primary indications for PPM implantation include:
- Symptomatic sinus node dysfunction (sick sinus syndrome) with documented bradycardia or pauses
- Third-degree (complete) AV block
- Mobitz type II second-degree AV block
- Symptomatic Mobitz type I (Wenckebach) AV block
- Alternating bundle branch block
- Cardiac resynchronization therapy for heart failure with reduced ejection fraction and wide QRS
- After cardiac ablation procedures that result in AV block Additional indications include certain neuromuscular diseases with conduction abnormalities, syncope with documented pauses, and hypersensitive carotid sinus syndrome with syncope. The decision for PPM implantation is based on the correlation between symptoms and bradycardia, the severity and location of conduction disease, and the risk of progression to complete heart block, as recommended by the 2018 ACC/AHA/HRS guideline 1. PPMs work by delivering electrical impulses to stimulate the heart when the native conduction system fails, maintaining adequate heart rate and cardiac output to prevent symptoms like syncope, fatigue, and exercise intolerance that result from inadequate cerebral and systemic perfusion. In patients with symptomatic bradycardia or conduction disorder, clinicians and patients should engage in a shared decision-making approach in which treatment decisions are based not only on the best available evidence, but also on the patient’s goals of care, preferences, and values, as stated in the 2018 ACC/AHA/HRS guideline 1.
From the Research
Indications for Permanent Pacemaker (PPM) Implantation
The indications for PPM implantation are varied and depend on the underlying cardiac condition. Some of the common indications include:
- Symptomatic bradycardia associated with sick sinus syndrome and heart block 2
- Complete atrioventricular block 3
- Symptomatic bradycardia/slow atrial fibrillation 3
- Second-degree atrioventricular block 3
- Other conduction disturbances 3
- Sinus node dysfunction (bradycardia, sinus arrest with junctional escape) 4
- Symptomatic complete heart block 4
- Symptomatic sinus pause 4
Patient Characteristics and PPM Implantation
Certain patient characteristics can influence the need for PPM implantation, such as:
- Preexisting conduction disturbances 3
- Aortic valve replacement 3
- Left bundle branch block 3
- Age and gender 5
- Index arrhythmia and initial symptoms 5
Post-Operative Care and Complications
After PPM implantation, patients require regular follow-up to monitor the device and adjust settings as needed. Complications can occur, including: