Bradycardia surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: M.Umer Tariq [2] Ibtisam Ashraf, M.B.B.S.[3] Nehal Eid, M.D.[4]

Overview

Surgery is not the first-line treatment option for patients with bradycardia. However, a temporary pacemaker followed by permanent pacemaker therapy may be required in some conditions.

Surgery

Temporary Pacemaker

• In general, temporary cardiac pacing is indicated when a bradyarrhythmia causes symptoms and/or severe hemodynamic impairment and when permanent cardiac pacing is not immediately indicated, not available, or the risk of inserting a permanent pacemaker exceeds potential benefit.
• Temporary pacemaker is most commonly used for patients with symptomatic bradyarrhythmias, most frequently due to atrioventricular (AV) nodal block.

Permanent Pacemaker

• Permanent Pacemaker is indicated in sinus node dysfunction, AV block, post MI and neurally-mediated syncope.

Permanent Pacing

Permanent Pacing for SND

Class I

1. In patients with symptoms that are directly attributable to SND, permanent pacing is indicated to increase heart rate and improve symptoms. (Level of Evidence: C-LD)

2. In patients who develop symptomatic sinus bradycardia as a consequence of guideline-directed management and therapy for which there is no alternative treatment and continued treatment is clinically necessary, permanent pacing is recommended to increase heart rate and improve symptoms. (Level of Evidence: C-EO)

Class IIa

1. For patients with tachy-brady syndrome and symptoms attributable to bradycardia, permanent pacing is reasonable to increase heart rate and reduce symptoms attributable to hypoperfusion. (Level of Evidence: C-EO)

2. In patients with symptomatic chronotropic incompetence, permanent pacing with rate-responsive programming is reasonable to increase exertional heart rates and improve symptoms. (Level of Evidence: C-EO)

Class III (Harm)

1. In asymptomatic individuals with sinus bradycardia or sinus pauses that are secondary to physiologically elevated parasympathetic tone, permanent pacing should not be performed. (Level of Evidence: C-LD)

2. In patients with sleep-related sinus bradycardia or transient sinus pauses occurring during sleep, permanent pacing should not be performed unless other indications for pacing are present. (Level of Evidence: C-LD)

3. In patients with asymptomatic SND, or in those in whom the symptoms have been documented to occur in the absence of bradycardia or chronotropic incompetence, permanent pacing should not be performed. (Level of Evidence: C-LD)

Pacing Mode Selection for SND

Class I

1. In symptomatic patients with SND, atrial-based pacing is recommended over single chamber ventricular pacing. (Level of Evidence: B-R)

2. In symptomatic patients with SND and intact atrioventricular conduction without evidence of conduction abnormalities, dual chamber or single chamber atrial pacing is recommended. (Level of Evidence: B-R)

Class IIa

1. In symptomatic patients with SND who have dual chamber pacemakers and intact atrioventricular conduction, it is reasonable to program the dual chamber pacemaker to minimize ventricular pacing. (Level of Evidence: B-R)

2. In symptomatic patients with SND in which frequent ventricular pacing is not expected or the patient has significant comorbidities that are otherwise likely to determine the survival and clinical outcomes, single chamber ventricular pacing is reasonable. (Level of Evidence: C-EO)

Four major RCTs compared the efficacy of AAI or DDD (collectively known as atrial-based) versus VVI (single chamber ventricular) pacing. Although the trials were very different with respect to study design, outcome definition, and duration of follow-up, the most consistent clinical benefit of dual chamber pacing over single chamber ventricular pacing was reduction in incidence of atrial fibrillation. Single chamber ventricular pacing cannot provide atrioventricular synchrony, which can lead to pacemaker syndrome, characterized by uncoordinated depolarizations and contractions between atria and ventricles leading to valvular regurgitation and heart failure–type symptoms such as chronic fatigue, dyspnea on exertion, and symptomatic hypotension.

Permanent Pacing for AV Block

Class I

1. In patients with acquired second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, or third-degree atrioventricular block not attributable to reversible or physiologic causes, permanent pacing is recommended regardless of symptoms. (Level of Evidence: B-NR)

2. In patients with neuromuscular diseases associated with conduction disorders, including muscular dystrophy (e.g., myotonic dystrophy type 1) or Kearns-Sayre syndrome, who have evidence of second-degree atrioventricular block, third-degree atrioventricular block, or an HV interval of 70 ms or greater, regardless of symptoms, permanent pacing, with additional defibrillator capability if needed and meaningful survival of greater than 1 year is expected, is recommended. (Level of Evidence: B-NR)

3. In patients with permanent atrial fibrillation and symptomatic bradycardia, permanent pacing is recommended. (Level of Evidence: C-LD)

4. In patients who develop symptomatic atrioventricular block as a consequence of guideline-directed management and therapy for which there is no alternative treatment and continued treatment is clinically necessary, permanent pacing is recommended to increase heart rate and improve symptoms. (Level of Evidence: C-LD)

Class IIa

1. In patients with an infiltrative cardiomyopathy, such as cardiac sarcoidosis or amyloidosis, and second-degree Mobitz type II atrioventricular block, high-grade atrioventricular block, or third-degree atrioventricular block, permanent pacing, with additional defibrillator capability if needed and meaningful survival of greater than 1 year is expected, is reasonable. (Level of Evidence: B-NR)

2. In patients with lamin A/C gene mutations, including limb-girdle and Emery-Dreifuss muscular dystrophies, with a PR interval greater than 240 ms and LBBB, permanent pacing, with additional defibrillator capability if needed and meaningful survival of greater than 1 year is expected, is reasonable. (Level of Evidence: B-NR)

3. In patients with marked first-degree or second-degree Mobitz type I (Wenckebach) atrioventricular block with symptoms that are clearly attributable to the atrioventricular block, permanent pacing is reasonable. (Level of Evidence: C-LD)

Class III (Harm)

1. In patients with first-degree atrioventricular block or second-degree Mobitz type I (Wenckebach) or 2:1 atrioventricular block which is believed to be at the level of the atrioventricular node, with symptoms that do not temporally correspond to the atrioventricular block, permanent pacing should not be performed. (Level of Evidence: C-LD)

2. In asymptomatic patients with first-degree atrioventricular block or second-degree Mobitz type I (Wenckebach) or 2:1 atrioventricular block which is believed to be at the level of the atrioventricular node, permanent pacing should not be performed. (Level of Evidence: C-LD)

Pacing Mode Selection for AV Block

Class I

1. In patients with SND and atrioventricular block who require permanent pacing, dual chamber pacing is recommended over single chamber ventricular pacing. (Level of Evidence: A)

2. In select patients with atrioventricular block who require permanent pacing in whom frequent ventricular pacing is not expected, or who have significant comorbidities that are likely to determine clinical outcomes and that may limit the benefit of dual chamber pacing, single chamber ventricular pacing is effective. (Level of Evidence: A)

3. For patients in sinus rhythm with a single chamber ventricular pacemaker who develop pacemaker syndrome, revising to a dual chamber pacemaker is recommended. (Level of Evidence: B-R)

Class IIa

1. In patients with atrioventricular block who have an indication for permanent pacing with a LVEF between 36% and 50% and are expected to require ventricular pacing more than 40% of the time, it is reasonable to choose pacing methods that maintain physiologic ventricular activation (e.g., cardiac resynchronization therapy [CRT] or His bundle pacing) over right ventricular pacing. (Level of Evidence: B-R)

2. In patients with atrioventricular block who have an indication for permanent pacing with a LVEF between 36% and 50% and are expected to require ventricular pacing less than 40% of the time, it is reasonable to choose right ventricular pacing over pacing methods that maintain physiologic ventricular activation (e.g., CRT or His bundle pacing). (Level of Evidence: B-R)

Class IIb

1. In patients with atrioventricular block at the level of the atrioventricular node who have an indication for permanent pacing, His bundle pacing may be considered to maintain physiologic ventricular activation. (Level of Evidence: B-R)

Class III (Harm)

1. In patients with permanent or persistent atrial fibrillation in whom a rhythm control strategy is not planned, implantation of an atrial lead should not be performed. (Level of Evidence: C-LD)

Conduction System Pacing

Conduction system pacing (CSP), which encompasses His bundle pacing (HBP) and left bundle branch area pacing (LBBAP), has emerged as a physiologic alternative to conventional right ventricular pacing. While right ventricular pacing is simple and reliable, chronic dyssynchronous activation can lead to pacing-induced cardiomyopathy, heart failure with reduced ejection fraction, incident atrial fibrillation, and an associated increase in mortality. CSP seeks to recruit the intrinsic His-Purkinje network to restore physiologic biventricular activation.

A meta-analysis of 5 randomized controlled trials enrolling 659 patients with AV block found that CSP was associated with a significant improvement in LVEF compared with right ventricular pacing (mean difference: 1.31%; 95% CI: 0.49 to 2.14; p < 0.01) and a significantly narrower paced QRS duration (mean difference: −28.44 ms; 95% CI: −38.96 to −17.92; p < 0.01), although procedure time was longer with CSP (mean difference: 25.86 min; 95% CI: 23.09 to 28.63; p < 0.01). The risk of device and lead-related complications was comparable between cohorts.

A larger meta-analysis of 19 studies comprising 5,390 patients (2,182 CSP; 3,208 RVP) found that CSP was associated with a reduction in all-cause mortality (RR 0.50, p < 0.0001), heart failure hospitalization (RR 0.39, p < 0.0001), and pacing-induced cardiomyopathy (RR 0.36, p = 0.039) compared with right ventricular pacing, although these findings should be interpreted in the context of predominantly observational data.

The 2025 ACC/AHA/ASE/HFSA/HRS/SCAI/SCCT/SCMR Appropriate Use Criteria note that the 2018 ACC/AHA/HRS guideline recommends that in patients with AV block and indications for permanent pacing with LVEF 36% to 50%, it is reasonable to choose pacing techniques providing more physiological ventricular activation (e.g., CRT, HBP) versus right ventricular pacing (Class IIa) if expected ventricular pacing is >40%.

Leadless Pacemakers

Leadless pacemakers were developed to avoid pacemaker pocket and lead-related complications associated with conventional transvenous pacing systems. Observational studies show a high success rate for implantation (approximately 99%) and a low rate of major complications. In observational studies using historical data or Medicare claims data on conventional transvenous pacemakers as controls, the risk of major complications with a leadless pacemaker was 31% to 63% lower than the risk with conventional transvenous pacemakers during the first year after implantation.

Per the 2021 ESC guidelines on cardiac pacing and cardiac resynchronization therapy, leadless pacemakers are indicated for patients without upper-extremity venous access (Class IIa, LOE: B) and for patients with a high expected benefit from leadless pacing, such as patients receiving hemodialysis or with a previous pacemaker infection (Class IIa, LOE: B). Leadless pacemakers may also be considered in all single-lead pacemaker candidates (Class IIb, LOE: C).

The most suitable candidates for leadless pacemakers include patients with bradyarrhythmias in combination with permanent atrial fibrillation or those with a dual-chamber pacemaker indication and a low expected pacing burden. Newer versions of leadless pacemakers can sense and track mechanical activity in the right atrium and pace in the right ventricle (VDD mode), although atrioventricular synchrony is not consistently achieved at lower rates and is lost at rates >135 bpm. Modular dual-chamber leadless pacing systems (with separate atrial and ventricular devices) are also available.

The 2025 ACC/AHA Appropriate Use Criteria rate leadless pacing as "Appropriate" in patients with permanent AF and anticipated pacing <40% when patient longevity is estimated to be shorter than battery longevity. In patients with sinus rhythm and complete heart block, leadless pacing "May Be Appropriate" with normal LV function but is "Rarely Appropriate" with LV dysfunction.

Long-Term Management

Follow-Up After Pacemaker Implantation

Patients with permanent pacemakers require regular follow-up to assess device function, battery longevity, lead integrity, and clinical status. Remote monitoring has become standard practice and allows for early detection of device malfunction, arrhythmias, and changes in pacing parameters.

Driving Restrictions

Driving restrictions after pacemaker implantation vary by jurisdiction and clinical scenario. In general, patients who have received a pacemaker for symptomatic bradycardia with syncope should refrain from driving for a period determined by local regulations and clinical judgment. Patients who received a pacemaker for non-syncopal symptoms may resume driving sooner, typically within days to weeks after implantation.