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©2013 UpToDate ® Print Email ACC/AHA/HRS guideline summary: Indications for permanent pacing in children, adolescents, and patients with congenital heart disease Class I - There is evidence and/or general agreement that permanent pacing should be performed in children, adolescents, and patients with congenital heart disease in the following settings: • Advanced second- or third-degree atrioventricular (AV) block that is associated with symptomatic bradycardia, ventricular dysfunction, or a low cardiac output. (Level of Evidence C) • Sinus node dysfunction with correlation of symptoms during age-inappropriate bradycardia. The definition of bradycardia varies with the patient's age and expected heart rate. (Level of Evidence B) • Postoperative advanced second- or third-degree AV block that is not expected to resolve or that persists for at least 7 days after cardiac surgery. (Level of Evidence B) • Congenital third-degree AV block with a wide QRS escape rhythm, complex ventricular ectopy, or ventricular dysfunction. (Level of Evidence B) • Congenital third-degree AV block in the infant with a ventricular rate less than 55 bpm or with congenital heart disease and a ventricular rate less than 70 bpm. (Level of Evidence C) Class IIa - Based upon the weight of evidence or opinion, it is reasonable to perform permanent pacing in children, adolescents, and patients with congenital heart disease in the following settings: • Sinus bradycardia for the prevention of recurrent episodes of intra-atrial reentrant tachycardia; SND may be intrinsic or secondary to antiarrhythmic treatment. (Level of Evidence: C) • Congenital third-degree AV block beyond the first year of life with an average heart rate less than 50 bpm, abrupt pauses in ventricular rate that are two or three times the basic cycle length, or symptoms due to chronotropic incompetence. (Level of Evidence: B) • Sinus bradycardia with complex congenital heart disease with a resting heart rate less than 40 bpm or pauses in ventricular rate lasting longer than three seconds. (Level of Evidence: C) • Impaired hemodynamics due to sinus bradycardia or loss of AV synchrony. (Level of Evidence: C) • Unexplained syncope in the patient with prior congenital heart surgery complicated by transient complete heart block with residual fascicular block after a careful evaluation to exclude other causes of syncope. (Level of Evidence: B)

• Impaired hemodynamics due to sinus bradycardia or loss of AV synchrony. (Level of Evidence: C) • Unexplained syncope in the patient with prior congenital heart surgery complicated by transient complete heart block with residual fascicular block after a careful evaluation to exclude other causes of syncope. (Level of Evidence: B) Class IIb - The weight of evidence or opinion is less well established, permanent pacing may be considered in children, adolescents, and patients with congenital heart disease in the following settings: • Transient postoperative third-degree AV block that reverts to sinus rhythm with residual bifascicular block. (Level of Evidence: C) • Congenital third-degree AV block in asymptomatic children or adolescents with an acceptable rate, a narrow QRS complex, and normal ventricular function. (Level of Evidence: B) • Asymptomatic sinus bradycardia after biventricular repair of congenital heart disease with a resting heart rate less than 40 bpm or pauses in ventricular rate longer than 3 seconds. (Level of Evidence: C) Class III - There is evidence and/or general agreement that permanent pacing should not be performed in children, adolescents, and patients with congenital heart disease in the following settings: • Transient postoperative AV block with return of normal AV conduction in the otherwise asymptomatic patient. (Level of Evidence: B) • Asymptomatic bifascicular block with or without first-degree AV block after surgery for congenital heart disease in the absence of prior transient complete AV block. (Level of Evidence: C) • Asymptomatic type I second-degree AV block. (Level of Evidence: C) • Asymptomatic sinus bradycardia if the longest relative risk interval less than three seconds and a minimum heart rate more than 40 bpm. (Level of Evidence: C) Adapted from Epstein, AE, DiMarco, JP, Ellenbogen, KA, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm Abnormalities: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) developed in collaboration with the American Association for Thoracic Surgery and Society of Thoracic Surgeons. J Am Coll Cardiol 2008; 51:e1.