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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 e436 CLINICAL STATEMENTS AND GUIDELINES significantly worse mortality (HR: 1.17; 95% CI: 1.00–1.36) and a decrease in LVEF to ≤35% (HR: 1.34; 95% CI: 1.09–1.63).S7.5-8 PROSPECT (Predictors of Response to CRT Trial) enrolled patients with LVEF of ≤35%, QRS interval >130 ms and Class III/IV heart failure. In a post hoc analysis, patients with an LVEF of >35% (when assessed by the core laboratory) had similar clinical and echocardiographic responses to CRT compared with patients with an LVEF of ≤35%.S7.5-9 In the REVERSE (Resynchronization Reverses Remodeling in Systolic Left Ventricular Dysfunction) trial, patients could be enrolled if they had New York Heart Association class I/II heart failure symptoms and an LVEF of <40% (although mean LVEF was 27%). Patients with QRS prolongation and LBBB morphology were markers for a clinical benefit with CRT.S7.5-20 6. Several studies from the 1970s demonstrated no benefit from prophylactic pacing in asymptomatic patients with conduction disorders (combined RBBB and left anterior fascicular block, or bundle branch block) even in the presence of infranodal disease.S7.5-10,S7.5-11 Although PPM implant is a relatively low-risk cardiac procedure, complications including death range from 3% to 7% and there are significant long-term implications for pacing systems that use transvenous leads.S7.5-12–S7.5-15 8 SPECIAL POPULATIONS 8.1 Perioperative Management Management of bradycardia after cardiac surgery is primarily based on historical surgical practice. Typically, all patients receive temporary epicardial pacing wires at the time of cardiac surgery. These are suturesized wires placed on the atrial and/or ventricular epicardium with the proximal end brought out through the skin. The temporary wires are used if necessary for rate support or for maintaining atrioventricular synchrony and later removed by pulling them out from their exit at the skin. Bleeding from the removal of temporary wires can occasionally be the cause of cardiac tamponade, late surgical exploration, and even death.S8.1-1 The need for temporary pacing after cardiac surgery is highly variable (between 0.8% and 24%) and primarily depends on the type of cardiac surgery, as well as a number of risk factors such as: older age, AF, prior surgery, preoperative renal failure, and active endocarditis.S8.1-2–S8.1-4 8.1.1 Patients at Risk for Bradycardia During Noncardiac Surgery or Procedures Recommendations for Patients at Risk for Bradycardia During Noncardiac Surgery or Procedures Referenced studies that support recommendations are summarized in Online Data Supplements 42, 44, and 45. COR LOE Recommendations IIa B-NR 1. In patients who are thought to be at high risk for the development of intraoperative or periprocedural bradycardia because of patient characteristics or procedure type, placement of transcutaneous pacing pads is reasonable.S8.1.1-1–S8.1.1-3 III: Harm B-NR 2. In patients with LBBB who require pulmonary artery catheterization for intraoperative monitoring, routine prophylactic temporary transvenous pacing should not be performed.S8.1.1-4,S8.1.1-5 Synopsis The development of significant bradycardia during surgery can be attributable to both patient-related and procedure-related factors. Several retrospective studies have identified age (>60-65 years of age), comorbidities (American Society of Anesthesia Class III or IV), lower heart rates (<60 bpm) or blood pressure (<110/60 mm Hg) at baseline, and use of concomitant drugs such as beta blockers or drugs that block the renin-angiotensin system as risk factors for the development of intraoperative bradycardia and hypotension in patients undergoing non-cardiac surgery.S8.1.1-6–S8.1.1-8 Because the right bundle branch is located near the endocardial surface of the RV, transient RBBB can occur during placement of pulmonary artery catheters for use during intraoperative monitoring.S8.1.1-1,S8.1.1-4,S8.1.1-5 A number of case reports and small series have identified several non-cardiac procedures that are more likely to be associated with bradycardia. In particular, procedures that could potentially activate the trigeminal cardiac reflex or vagus nerve, for example, maxillofacial surgeries or carotid endarterectomy or stenting, or other neurosurgical procedures that involve manipulation of the spine or dura mater have been reported to cause bradycardia.S8.1.1-3,S8.1.1-9–S8.1.1-12 Others have identified peritoneal insufflation as a possible critical period during abdominal surgery associated with significant bradycardia.S8.1.1-13,S8.1.1-14 Recommendation-Specific Supportive Text 1. Older patients with comorbidities (American Society of Anesthesia Class III or IV) and low heart rates at baseline are at higher risk for the devel- Downloaded from http://ahajournals.org by on October 7, 2026