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Expanding Indications for Permanent Pacemakers

Michael Glikson, MD; Raul E. Espinosa, MD; and David L. Hayes, MD
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From the Mayo Clinic and Mayo Foundation, Rochester, Minnesota. Requests for Reprints: David L. Hayes, MD, Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. Current Author Addresses: Drs. Hayes and Espinosa: Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1995;123(6):443-451. doi:10.7326/0003-4819-123-6-199509150-00009
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Purpose: To review the current clinical experience with new and expanding indications for permanent cardiac pacing.

Data Sources: A MEDLINE search was done of the English-language literature published from 1980 through 1994 about indications for permanent pacing. Five major areas were identified and searched: cardiomyopathies, atrial fibrillation, the long QT syndrome, cardiac transplantation, and vasovagal syncope. A manual search was then done for other contributions, including abstracts.

Study Selection: Because published reports in these areas are scarce, all of the peer-reviewed articles and most of the relevant abstracts found were reviewed.

Data Extraction: Data were manually extracted from the various sources, and the reports were classified and summarized according to specific indications.

Results: Pacing is becoming an important option in the treatment of patients with symptomatic drug-resistant hypertrophic obstructive cardiomyopathy. Symptomatic and hemodynamic benefits have been shown in patients with pacing over various periods of follow-up. In patients with the long QT syndrome in whom medical therapy had failed, pacing at relatively fast rates markedly reduced symptoms and almost completely abolished fainting spells. Preliminary results suggest that pacing may be beneficial in dilated cardiomyopathy and in preventing episodes of paroxysmal atrial fibrillation. Further studies are needed to clarify the mechanisms of and to improve selection criteria for pacing in these conditions. Our ability to select cardiac transplant recipients for permanent pacing and our ability to optimize the timing of pacing in these patients have recently improved considerably. The role of pacing therapy in patients with neurally mediated (vasovagal) syncope remains incompletely understood. Better classification of these patients, made according to the sequence of hemodynamic events leading to syncope, is likely to clarify the potential benefit of pacing in these patients and improve the selection of patients for pacing.

Conclusion: Few peer-reviewed clinical trials have been done, and further studies are needed to confirm the promising effects of pacing in patients with these newly recognized and expanding indications for pacing.


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Figure 1.
Hemodynamic tracings from a patient with hypertrophic obstructive cardiomyopathy.

The initial portion of the tracing shows P-synchronous pacing (VD mode) with a very short atrioventricular (A-V) interval of 20 ms. Pacing is turned off after six cardiac cycles. The left ventricular outflow gradient, the difference from aorta (Ao) to left ventricle (LV), is considerably decreased with pacing. LA equals left atrium; PA equals pulmonary artery.

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Figure 2.
Still frame from a continuous-wave Doppler recording in a patient with dilated cardiomyopathy and a marked first-degree atrioventricular delay of 260 ms.Left.arrowheadRight.

With native rhythm, diastolic mitral regurgitation is evident ( ) and the peak velocity of mitral regurgitation is low, indicating high left atrial pressure. Pacing in the DDD mode at an atrioventricular interval of 100 ms. Diastolic mitral regurgitation has been abolished, and the peak velocity of mitral regurgitation has increased substantially. Because systemic blood pressure was similar in both examinations, the higher mitral regurgitation peak velocity suggests that dual-chamber pacing at an abbreviated atrioventricular interval has reduced left atrial pressure.

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