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Kusumoto et al 2018 Bradycardia Clinical Practice Guidelines

August 20, 2019 Circulation. 2019;140:e382–e482. DOI: 10.1161/CIR.0000000000000628 e422

CLINICAL STATEMENTS AND GUIDELINES acute treatment of atrioventricular block because of the painful nature of the stimulation and difficulty in ascertaining reliable myocardial capture.S6.3.3-22 Figure 5 provides an algorithm for choosing specific pacing strategy once temporary pacing is thought to be clinically necessary.

Recommendation-Specific Supportive Text

1.	 Temporary transvenous pacing was introduced in 1959 and is now widely available. Use of semirigid fixed curve catheters were associated with high complication rates, particularly in the acute MI setting and when placed by less-experienced operators.S6.3.3-1,S6.3.3-2,S6.3.3-7 One randomized trial showed faster placement and lower complication rates with balloon-tipped catheters.S6.3.3-6 Nonrandomized data suggest lower complication rates using internal jugular vein access and fluoroscopic or echocardiographic guidance (for venous access and lead position) for placement.S6.3.3-4,S6.3.3- 5,S6.3.3-23 Complications for transvenous pacing wires are greater when left in place for longer duration (>48 hours), which may delay placement of a PPM.S6.3.3-3 Temporary transvenous pacing should therefore be used for the minimum duration necessary to provide hemodynamic support or back-up pacing to prevent asystole and should be placed by the most experienced available operator. If atrioventricular block is felt to be irreversible, and the means to place a permanent pacing system is available, it may be best for the patient to avoid temporary pacing and proceed directly to permanent system implantation. 2.	 Use of an active fixation permanent pacing lead externalized and connected to a reusable PPM generator (sometimes referred to as a “temporary PPM”) has been introduced as a means of allowing more prolonged temporary pacing for pacemaker-dependent patients who have a contraindication to PPM implantation, such as infection. A primary use is for bridging therapy in patients who have undergone CIED extraction for infection and require prolonged antibiotic treatment.S6.3.3-11 Patients receiving long-term antibiotics who will be receiving a new pacemaker benefit from externalized devices during the course of therapy.S6.3.3-24 Non-RCTs and cohort studies suggest that this form of temporary pacing is associated with much lower dislodgment rates and lower complication rates overall.S6.3.3-8–S6.3.3-14 Other advantages include ability to mobilize patients who would otherwise be confined to bedrest in an intensive care unit setting. One study suggested that this form of pacing is cost saving after 1 to 2 days, despite the higher lead cost because of ability to care for the patient in a lower intensity/lower cost setting.S6.3.3-9 No infections have been reported with the use of reusable sterilized pacemakers.S6.3.3-8–S6.3.3-14

3.	 Transcutaneous pacing was reported in 1952 and became commercially available in the early 1980s.S6.3.3-20 It is now universally available in combination with external defibrillators. Numerous trials have not shown any improvement in survival to hospital discharge when used in the prehospital phase of bradyasystolic cardiac arrest.S6.3.3-16–S6.3.3-19 Its use appears to be greater when applied to patients with a perfusing rhythm or early in the course of cardiac arrest.S6.3.3-15,S6.3.3-17 There are no controlled trials of transcutaneous pacing outside the setting of prehospital cardiac arrest. Use of transcutaneous pacing may be limited by high capture thresholds and patient discomfort, which may require sedation. Assessment of myocardial capture by ECG alone may be difficult and should be confirmed by assessment of pulse or intra-arterial pressure. Because prolonged use of transcutaneous pacing may be unreliable and poorly tolerated, it should generally serve as a short-term bridge to temporary or permanent transvenous pacing or resolution of bradycardia. However, prophylactic placement of pads for rapid institution of temporary pacing, if necessary, is reasonable in patients who are thought to be at future risk for significant bradycardia.S6.3.3-25

6.4 Chronic Therapy/Management

of Bradycardia Attributable to Atrioventricular Block

An algorithm for the management of bradycardia or pauses attributable to chronic atrioventricular block is provided in Figure 7. Specific subsections address general principles, transient or potentially reversible causes, additional testing, and permanent pacing for chronic atrioventricular block.

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