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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 e444

CLINICAL STATEMENTS AND GUIDELINES have not been consistent from study to study and have included preprocedure first-degree atrioventricular blockS8.1.2.5.2-1 or LBBB,S8.1.2.5.2-2 transient atrioventricular block and new RBBB after the procedure.S8.1.2.5.2-4 In 1 study, the first manifestation of atrioventricular block occurred between 2 days and 3 years in 9% of patients after alcohol septal ablation.S8.1.2.5.2-21 In another study, outpatient rhythm monitoring with implantable loop recorders was initiated after alcohol septal ablation.S8.1.2.5.2-8 Although there were episodes of ventricular fibrillation associated with complete heart block in the immediate periprocedural period, no episodes of heart block were identified after discharge.S8.1.2.5.2-8 Late development of atrioventricular block after surgical myectomy has not been reported with limited follow-up.S8.1.2.5.2-7,S8.1.2.5.2-15

4.	 In 1 study of 172 patients who underwent simultaneous alcohol septal ablation and EPS, those patients with intact retrograde ventriculoatrial conduction did not develop late complete heart block regardless of changes in anterograde atrioventricular conduction properties associated with the alcohol septal ablation.S8.1.2.5.2-9 8.1.2.6. Managing Episodes of Bradycardia Associated With Postoperative AF AF occurs commonly after cardiac surgery in adults, with a peak incidence 2 to 4 days postoperatively and an overall incidence ranging from 10% to 65%.S8.1.2.6- 1 Postoperative AF occurs more frequently in patients undergoing valve surgery than in those undergoing isolated coronary artery bypass graft.S8.1.2.6-2 Bradycardia may take several forms in these patients, including slow ventricular response during AF and prolonged sinus pauses after sinus rhythm is restored. A slow and regular ventricular response during AF usually indicates complete heart block, and pacing may be required if resolution does not occur.S8.1.2.6-3 The assessment of bradyarrhythmias in this setting is often complicated by the coexistence of atrial tachyarrhythmia; transient and time-dependent postoperative effects on sinus and atrioventricular node function, and the potential presence of antiarrhythmic drugs.S8.1.2.6-4 In general, bradyarrhythmias in the setting of postoperative AF should be treated similarly to those occurring in the nonoperative setting, and a period of watchful waiting rather than early PPM implantation is generally used. In occasional patients with refractory AF with rapid ventricular responses associated with significant SND limiting rate control drugs, a PPM may be required for adequate AF management. 8.2 Bradycardia Management for Adult

Congenital Heart Disease

Recommendations for Management of Bradycardia in Adults With Adult Congenital Heart Disease Referenced studies that support recommendations are summarized in Online Data Supplement 53.

COR LOE Recommendations

I B-NR 1.  In adults with adult congenital heart disease (ACHD) and symptomatic SND or chronotropic incompetence, atrial based permanent pacing is recommended.S8.2-1–S8.2-6

I B-NR 2.  In adults with ACHD and symptomatic bradycardia related to atrioventricular block, permanent pacing is recommended.S8.2-7–S8.2-9

I B-NR 3.  In adults with congenital complete atrioventricular block with any symptomatic bradycardia, a wide QRS escape rhythm, mean daytime heart rate below 50 bpm, complex ventricular ectopy, or ventricular dysfunction, permanent pacing is recommended.S8.2-10,S8.2-11

I B-NR 4.  In adults with ACHD and postoperative second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, or third-degree atrioventricular block that is not expected to resolve, permanent pacing is recommended.S8.2-12,S8.2-13

IIa B-NR 5.  In asymptomatic adults with congenital complete atrioventricular block, permanent pacing is reasonable.S8.2-7–S8.2-11

IIa B-NR 6.  In adults with repaired ACHD who require permanent pacing for bradycardic indications, a bradycardia device with atrial antitachycardia pacing capabilities is reasonable.S8.2-14,S8.2-15

IIa C-EO 7.  In adults with ACHD with preexisting sinus node and/or atrioventricular conduction disease who are undergoing cardiac surgery, intraoperative placement of epicardial permanent pacing leads is reasonable.

IIb B-NR 8.  In adults with ACHD and pacemakers, atrialbased permanent pacing for the prevention of atrial arrhythmias may be considered.S8.2-3–

S8.2-5,S8.2-16

III: Harm B-NR 9.  In selected adults with ACHD and venous to systemic intracardiac shunts, placement of endocardial pacing leads is potentially harmful.S8.2-17,S8.2-18

Synopsis

Adults with congenital heart disease are a diverse group of patients with varied anatomies of the conduction system, venous return to the heart, cardiac repairs and also progression of conduction system disease. This set of recommendations is focused specifically on the adult (and not the pediatric patient) with ACHD, using adult-specific references or expert consensus only. Many congenital heart disease syndromes have their specific considerations, such as preprocedure imaging of patients with a prior atrial switch to ensure no clini-

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