Is a pacemaker recommended for a patient with Hypertrophic Obstructive Cardiomyopathy (HOCM), 5% non-scheming scar burden, and Mobitz I bradycardia, who has experienced multiple falls?

Pacemaker Recommendation for HOCM Patient with Mobitz I Bradycardia and Multiple Falls

A permanent pacemaker is recommended for this 61-year-old man with HOCM, 5% non-ischemic scar burden, Mobitz I bradycardia, and multiple falls, as he meets criteria for bradycardia pacing and may additionally benefit from reduction in LVOT obstruction. 1

Primary Indication: Bradycardia with Falls

• Mobitz I bradycardia in a patient with multiple falls represents a strong indication for permanent pacemaker implantation, as bradycardia can contribute to falls and syncope 1
• The presence of multiple falls in this patient suggests a potential causal relationship between the bradycardia and his symptoms, which supports pacemaker implantation 1
• Studies have shown that pacing can reduce syncope recurrence and fall events in patients with bradycardia-related symptoms 1

Additional Benefit in HOCM

• In patients with HOCM who require pacing for bradycardia indications, there is an additional potential benefit of reducing left ventricular outflow tract obstruction 1
• While pacing is not a first-line therapy for HOCM symptom management, it is reasonable to consider dual-chamber pacing for patients with HOCM who have had a device implanted for non-HOCM indications 1
• The American College of Cardiology/American Heart Association guidelines specifically state that DDD pacing can be useful for patients with medically refractory, symptomatic HOCM with significant resting or provoked left ventricular outflow obstruction 1

Pacing Mode Considerations

• A dual-chamber (DDD) pacemaker is preferred over a single-chamber device in this patient with HOCM 1
• DDD pacing with a short AV delay can reduce LVOT gradient by altering septal activation pattern and increasing end-systolic volume 1
• Right ventricular apical pacing is the recommended location to achieve the greatest reduction in LVOT gradient 1

Cautions and Considerations

• Bradycardia can actually worsen LVOT obstruction in HOCM, making this patient's Mobitz I bradycardia potentially more symptomatic than in patients without HOCM 2
• The patient's 5% non-ischemic scar burden should be considered when evaluating overall risk, but does not contraindicate pacemaker implantation 1
• Pacemaker implantation carries a small risk of complications including pneumothorax (1.5-2%), lead dislodgement (1-4%), and device malfunction (0.1-0.2%) 1
• Shared decision-making should be employed, discussing the benefits of symptom improvement and fall prevention against the risks of the procedure 1

Programming Recommendations

• Program a relatively short AV delay (typically 100-150 ms) to ensure ventricular pre-excitation and maximize reduction in LVOT gradient 1, 3
• Set an upper rate limit higher than the fastest sinus rate achievable during exercise to prevent functional atrial undersensing 1
• Consider rate-responsive features to maintain appropriate heart rate during activity, as heart rate increase during exercise is important for maintaining cardiac output 4

Follow-up Recommendations

• Regular device checks to ensure proper functioning and optimization of AV delay 3
• Continued monitoring for symptoms of HOCM and bradycardia 1
• Assessment of LVOT gradient reduction after pacemaker implantation to evaluate effectiveness 3