p.48 抽出テキスト

............................................................................................................................................................................. <150 ms may not require further evaluation during hospitalization. When EPS is contemplated, it should be performed >_3 days postprocedure and after the conduction abnormalities have stabilized.

The type of permanent pacemaker implanted should follow standard guidance (see sections 5, 6, and 7). Given the low rates of longterm dependency on pacing,544,545 algorithms promoting spontaneous AV conduction should be used.

8.4 Cardiac pacing and cardiac

resynchronization therapy in congenital heart disease Permanent pacing in patients with moderate or complex CHD should be performed in centres with a multidisciplinary team and expertise in CHD-related device therapy. Generally, decision-making for pacemaker therapy in patients with CHD is based on expert consensus and individual evaluation due to lack of evidence from RCTs. In the presence of an intracardiac shunt between the systemic and pulmonary circulation, endovascular lead placement is relatively contraindicated due to the risk of arterial embolism.551

The clinical presentation may vary considerably; even severe bradycardia in congenital AVB may remain oligosymptomatic or asymptomatic. Periodic Holter recordings may be useful for patients at specific risk of bradyarrhythmia.

8.4.1 Sinus node dysfunction and bradycardiatachycardia syndrome There is no evidence that SND directly leads to increased mortality in CHD. However, it may be associated with a higher rate of postoperative atrial flutter, with 1:1 AV conduction in CHD, and thus lead to morbidity and potentially mortality.552,553

8.4.1.1 Indications for pacemaker implantation In patients with symptomatic chronotropic incompetence, pacemaker implantation is justified when other causes (see section 4) have been ruled out.554,555 Increasing the heart rate through permanent pacing to prevent atrial arrhythmias may be considered.556 The underlying evidence is weak, as the benefit of atrial-based pacing observed in patients without structural heart disease could not be validated in CHD.21,557,558 The general consensus is that if permanent pacing is necessary, single-lead atrial-based pacing should be preferred to limit the number of leads, especially in young patients with adequate AV conduction.559 In patients with congenitally corrected transposition of the great arteries requiring ventricular pacing because of high-degree AVB, CRT should be considered. Current evidence to use devices with atrial antitachycardia pacing to treat intra-atrial re-entrant tachycardias in patients with CHD560,561 is too limited to make general recommendations.

8.4.2 Congenital atrioventricular block A number of maternal or fetal factors can cause congenital heart block, particularly autoimmune diseases such as systemic lupus erythematosus and Sjo ̈gren syndrome (Supplementary Table 16). Patients presenting with congenital AVB may be asymptomatic or may present with reduced exercise capacity, syncopal attacks, congestive HF, ventricular dysfunction, and dilatation. Rarely, in SCD, congenital AVB is diagnosed as the cause.562,563 SCD may occur through increased propensity to develop bradycardia-related ventricular arrhythmias such as torsades-de-pointes.

8.4.2.1 Indications for pacemaker implantation There is general consensus that prophylactic pacing is indicated in asymptomatic patients with any of the following risk factors: mean daytime heart rate <50 b.p.m., pauses greater than three times the cycle length of the ventricular escape rhythm, a broad QRS escape rhythm, prolonged QT interval, or complex ventricular ectopy.564566 Clinical symptoms, such as syncope, pre-syncope, HF, or chronotropic incompetence, are indications for pacemaker implantation.564,567,568 If ventricular dysfunction is attributed to haemodynamic compromise caused by bradycardia, permanent pacing may be indicated.518,567 Despite a modest quality of evidence, there

Recommendations for cardiac pacing after transcatheter aortic valve implantation

Recommendations Classa Levelb

Permanent pacing is recommended in patients with complete or high-degree AVB that persists for 24 - 48 h after TAVI.546 I B Permanent pacing is recommended in patients with new-onset alternating BBB after TAVI.533,547 I C Earlyc permanent pacing should be considered in patients with pre-existing RBBB who develop any further conduction disturbance during or after TAVI.d IIa B Ambulatory ECG monitoringe or EPSf should be considered for patients with new LBBB with QRS >150 ms or PR >240 ms with no further prolongation during the >48 h after TAVI.536,537,548 IIa C Ambulatory ECG monitoringe or EPSf may be considered for patients with a pre-existing conduction abnormality who develop prolongation of QRS or PR >20 ms.g IIb C Prophylactic permanent pacemaker implantation is not indicated before TAVI in patients with RBBB and no indication for permanent pacing. III C

AF = atrial fibrillation; AVB = atrioventricular block; BBB = bundle branch block; CRT = cardiac resynchronization therapy; ECG = electrocardiogram; EPS = electrophysiology study; HV = Hisventricular interval; LBBB = left bundle branch block; RBBB = right bundle branch block; SR = sinus rhythm; TAVI = transcatheter aortic valve implantation. For the definition of alternating BBB, see section 5.3.1. aClass of recommendation. bLevel of evidence. cImmediately after procedure or within 24 h. dTransient high-degree AVB, PR prolongation, or QRS axis change. eAmbulatory continuous ECG monitoring (implantable or external) for 730 days.536,549 fEPS should be performed >_3 days after TAVI. Conduction delay with HV >_70 ms may be considered positive for permanent pacing.540,541,550 gWith no further prolongation of QRS or PR during 48-h observation. Note: CRT in patients requiring pacing after TAVI has the same indication as for general patients (see section 6). ESC 2021 Downloaded from academic.oup.com/eurheartj/article/42/35/3427/6358547 by guest on 07 October 2026