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Indications for Pacing in Patients With Unexplained Syncope and Bifascicular Block

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Syncope

Abstract

Bifascicular block is defined as complete left bundle-branch block, complete right bundle-branch block with left anterior hemiblock or left posterior hemiblock (QRS > 120 ms).

Practice Guidelines have given a class II-A recommendation for pacemaker implantation in patients with bifascicular block and syncope of apparently unexplained origin in order to avoid the risk of syncopal recurrences and potential physical trauma.

The PRESS study was designed to assess the role of dual chamber pacing in preventing symptom recurrences in these patients. The study included patients with bifascicular block and of syncope of unknown origin after being studied with non-invasive and invasive tests. PRESS study demonstrated that a pacemaker programmed with a lower rate of 60 bpm resulted in a significant reduction of the combination of: syncope, presyncope, AV block, or episodes of cardioinhibitory origin when compared with DDI 30 bpm.

The 2017 ACC/AHA/HRS guidelines support the previous recommendations for patients with syncope and bifascicular block without documented high-degree AV block, having excluded other causes for the AV block. (Class I Level C- EO).

The 2018 ESC Guidelines justified an upgrade of the recommendation for EPS-Guided cardiac pacing in patients with a positive EPS from class IIa to class I.

Empirical pacing is not advised in patients with bifascicular block without evidence of prolonged HV or intermittent AV block. The above considerations justify a class IIb indication. The Guidelines recommend a strategy of EPS followed by ILR if the EPS findings are unremarkable in patients with LVEF > 35%. In patients with bifascicular block and low ejection fraction (EF < 35%) an ICD or CRT-D is indicated for the prevention of SCD and consequently the pacing indication is superseded.

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Author information

Authors and Affiliations

  1. Chief of Electrophysiology Division at Bazterrica Clinic, Buenos Aires, Argentina

    Oscar Oseroff

  2. Director of the Electrophysiology Division, Favaloro Foundation, Buenos Aires, Argentina

    Nestor O. Galizio

Authors
  1. Oscar Oseroff
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  2. Nestor O. Galizio
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Editor information

Editors and Affiliations

  1. Faint & Fall Programme, IRCCS Istituto Auxologico Italiano Ospedale San Luca, Piazzale Brescia, Milano, Italy

    Michele Brignole

  2. University of Minnesota, MMC 508, Minneapolis, MN, USA

    David G. Benditt

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Oseroff, O., Galizio, N.O. (2020). Indications for Pacing in Patients With Unexplained Syncope and Bifascicular Block. In: Brignole, M., Benditt, D. (eds) Syncope. Springer, Cham. https://doi.org/10.1007/978-3-030-44507-2_21

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  • DOI: https://doi.org/10.1007/978-3-030-44507-2_21

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-44506-5

  • Online ISBN: 978-3-030-44507-2

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