What is the treatment for Premature Premature Contractions (PPM)?

From the Guidelines

PPM implantation should be avoided in the early stages of an acute MI, unless there is a high-degree atrioventricular block or other indications that necessitate permanent pacing, as the natural course of an MI with conduction system abnormalities is frequently associated with recovery of conduction 1. The decision to implant a PPM in patients with bradycardia and cardiac conduction delay should be based on the clinical presentation, location of infarct, and associated myocardial damage. Some key points to consider when evaluating the need for PPM implantation include:

• The type and location of the conduction disturbance, as well as the presence of hemodynamic compromise secondary to significant bradycardia 1
• The potential for recovery of conduction, as temporary atrioventricular block is common in the setting of an acute MI 1
• The risks associated with PPM implantation, including complications such as death, which can range from 3% to 7%, and significant long-term implications for pacing systems that use transvenous leads 1
• The potential benefits of avoiding unnecessary pacing, as early and unnecessary pacing should be avoided in patients with an acute MI and conduction system abnormalities 1 In general, the clinician should carefully consider and generally avoid early permanent pacing (<72 hours) in patients with an acute MI, so as to potentially avoid unnecessary implantation of pacemakers 1. Additionally, it may be reasonable to consider CIED with defibrillator capacity in patients with pacing requirement and low LVEF, as indicated in other scientific society statements 1. Overall, the decision to implant a PPM in patients with bradycardia and cardiac conduction delay should be based on a careful evaluation of the individual patient's clinical presentation and needs, and should take into account the potential risks and benefits of PPM implantation.

From the Research

PPM Overview

• PPM (Permanent Pacemaker) is a medical device used to treat certain heart conditions, such as bradycardia, by generating electrical impulses to regulate the heartbeat 2.
• The use of PPM is indicated in patients with symptomatic bradyarrhythmias caused by sinus node dysfunction, and in those with frequent, prolonged sinus pauses 2.

Indications for PPM Implantation

• Patients with third-degree or complete atrioventricular (AV) block benefit from pacemaker placement, as do those with type II second-degree AV block because of the risk of progression to complete AV block 2.
• The use of pacemakers in patients with type I second-degree AV block is controversial, and patients with first-degree AV block generally should not receive a pacemaker except when the PR interval is significantly prolonged and the patient is symptomatic 2.
• Cardiac resynchronization therapy improves mortality rates and some other disease-specific measures in patients who have a QRS duration of 150 milliseconds or greater and New York Heart Association class III or IV heart failure 2.

PPM Placement and Lead Installation

• PPM placement in the apical Right Ventricle (RV) and Right Ventricular Outflow Tract (RVOT) has been compared, and pacing burden >40% causes subclinical left ventricular systolic dysfunction after a month of PPM implantation with decreased Global Longitudinal Strain (GLS) in apical RV pacing 3.
• The use of a dual-chamber PPM device, with leads placed in RVOT and the right atrium with atrial-ventricle synchronization, can help avoid impaired left ventricular pump function 3.

Temporary Permanent Pacemakers

• Temporary cardiac pacing is commonly used in patients with life-threatening bradycardia and serves as a bridge to implantation of a permanent pacemaker (PPM) 4.
• The use of temporary permanent pacemakers (TPPMs) with active fixation leads has become increasingly popular, offering advantages such as a low risk of lead dislodgement and allowing patients to ambulate 4.

Risk Factors for Bradycardia Requiring PPM Implantation

• Heart failure and permanent AF each nearly triple the odds of developing bradycardia requiring a permanent pacemaker in patients with atrial fibrillation (AF) 5.
• Women are more likely and African Americans less likely to develop bradycardia requiring pacemaker implantation, although the results are not statistically significant 5.