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........................................................................................................................................................................... considered because most causes of inflammatory disease causing bradycardia may also result in reduced myocardial contractility and ventricular fibrosis.

8.6.6.1 Sarcoidosis Persistent or intermittent AVB can occur in sarcoidosis, which shows a propensity to involve the basal intraventricular septum. In a Finnish registry, 143 of 325 patients (44%) diagnosed with cardiac sarcoidosis had Mobitz II second- or third-degree AVB in the absence of other explanatory cardiac disease.626 A history of syncope, pre-syncope, or palpitations points towards bradycardia, but also to potential ventricular tachyarrhythmia. AVB is the most common clinical presentation in patients with clinically evident cardiac sarcoidosis.627,628 Diagnostic steps include ECG monitoring, echocardiography, cardiac MRI, and myocardial or other involved tissue biopsy. Fluorodeoxyglucosepositron emission tomography may be useful.629 The chances and time course of resolution of AVB with immunosuppressive therapy are not clear,630 but may be low.88 Long-term data are available mainly from a Canadian prospective study (32 patients),627 a Japanese retrospective study (22 patients),628 and a Finnish registry (325 patients).626 Reversibility of conduction disorder is unpredictable and, even in patients with transient AVB, permanent pacing should be considered.631 Immunosuppressive treatment may increase risk of device infection. However, there are no firm data to support device implantation before initiation of immunosuppressive medication. Patients with cardiac sarcoidosis and AVB are at high risk of SCD during long-term follow-up, even if LVEF is >35%.626 Patients with even a mild or moderate decrease in LVEF (3549%) are at increased risk of SCD.632,633 Therefore, in patients with cardiac sarcoidosis who have an indication for cardiac pacing and LVEF <50%, a CRT-D should be considered rather than a pacemaker634 (section 6).

8.7 Cardiac pacing in pregnancy

Vaginal delivery carries no extra risks in a mother with congenital complete heart block, unless contraindicated for obstetric reasons.635 For women who have a stable, narrow complex junctional escape rhythm, pacemaker implantation may not be necessary or can be deferred until after delivery if none of the risk factors (syncope, pauses >3 the cycle length of the ventricular escape rhythm, wide QRS escape rhythm, prolonged QT interval, complex ventricular ectopy, mean daytime heart rate <50 b.p.m.) is present. However, women with complete heart block who exhibit a slow, wide QRS complex escape rhythm should undergo pacemaker implantation during pregnancy. The risks of pacemaker implantation are generally low and can be performed safely, especially if the foetus is beyond 8 weeks gestation. A pacemaker for the alleviation of symptomatic bradycardia can be implanted at any stage of pregnancy using echo guidance or electroanatomic navigation minimizing fluoroscopy.636,637

9 Special considerations on device

implantations and peri-operative management

9.1 General considerations

Patients with clinical signs of active infection and/or fever should not undergo a permanent pacemaker (including leadless pacemaker) implantation until they have been afebrile for at least 24 h. Febrile patients who have been started on antibiotics should ideally receive a complete course of antibiotic treatment and should be afebrile for 24 h after termination of antibiotic treatment before definite pacemaker implantation is performed if acute pacing is not required. If possible, the use of temporary transvenous pacing should be avoided. In patients in need of acute pacing, temporary transvenous pacing should be established, preferably with jugular or axillar/lateral subclavian vein access.638 In a multicentre, prospective study with 6319 patients, fever within 24 h of implantation (OR 5.83, 95% CI 2.0016.98) and temporary pacing before implantation (OR 2.46, 95% CI 1.095.13) were positively correlated with the occurrence of device infection.639 In the case of patients with chronic recurrent infection, minimally invasive implantation of an epicardial pacemaker may be considered.

9.2 Antibiotic prophylaxis

The use of pre-operative systemic antibiotic prophylaxis is recommended as the standard of care in pacemaker implantation procedures. The risk of infection is significantly reduced with a single dose of prophylactic antibiotic (cefazolin 12 g i.v. or flucloxacillin 12 g i.v.) given within 3060 min [90120 min for vancomycin (15 mg/kg)] before the procedure.640643 The antibiotic prophylaxis should cover S. aureus species, but routine coverage of methicillinresistant S. aureus is not recommended. The use of vancomycin should be guided by patient risk for methicillin-resistant S. aureus colonization and the prevalence of the bacterium in the corresponding institution.638 In contrast, post-operative antibiotic prophylaxis does not reduce the incidence of infection.644,645

9.3 Operative environment and skin

antisepsis The pacemaker implantation procedure should be performed in an operating environment that meets the standards of sterility as required for other surgical implant procedures.638,646

Recommendations for pacing in cardiac sarcoidosis

Recommendations Classa Levelb

In patients with cardiac sarcoidosis who have permanent or transient AVB, implantation of a device capable of cardiac pacing should be considered.c 88,629,630 IIa C In patients with sarcoidosis and an indication for permanent pacing who have LVEF <50%, implantation of a CRT-D should be considered.631,634 IIa C

AVB = atrioventricular block; CRT-D = defibrillator with cardiac resynchronization therapy; ICD = implantable cardioverter-defibrillator; LVEF = left ventricular ejection fraction. aClass of recommendation. bLevel of evidence. cWhenever pacing is indicated in sarcoidosis, an ICD should be considered according to the relevant guidelines. ESC 2021 Downloaded from academic.oup.com/eurheartj/article/42/35/3427/6358547 by guest on 07 October 2026