Pacemaker Implantation Guidelines for Congenital Complete Heart Block

Class I Indications

The American College of Cardiology recommends permanent pacemaker implantation for congenital third-degree AV block in infants with a ventricular rate less than 55 bpm, or less than 70 bpm when associated with congenital heart disease 1, 2, 3
The American College of Cardiology recommends pacemaker implantation for congenital third-degree AV block with a wide QRS escape rhythm, complex ventricular ectopy, or ventricular dysfunction 2, 3, 4
The American College of Cardiology recommends pacemaker implantation for symptomatic bradycardia associated with advanced second- or third-degree AV block 2, 4
The American College of Cardiology recommends pacemaker implantation for advanced second- or third-degree AV block associated with ventricular dysfunction or low cardiac output 2, 3

The American College of Cardiology suggests pacemaker implantation for congenital third-degree AV block beyond the first year of life with an average heart rate <50 bpm 1, 2, 3
The American College of Cardiology suggests pacemaker implantation for congenital third-degree AV block with abrupt pauses in ventricular rate that are 2 or 3 times the basic cycle length 1, 2, 3
The American College of Cardiology suggests pacemaker implantation for congenital third-degree AV block with symptoms due to chronotropic incompetence 1, 2, 3
The American College of Cardiology suggests pacemaker implantation for unexplained syncope in patients with prior congenital heart surgery complicated by transient complete heart block with residual fascicular block 1, 2, 3
The American College of Cardiology suggests pacemaker implantation for impaired hemodynamics due to loss of AV synchrony in patients with congenital heart disease 2, 3

The American College of Cardiology may consider pacemaker implantation for transient postoperative third-degree AV block that reverts to sinus rhythm with residual bifascicular block 1, 2, 3
The American College of Cardiology may consider pacemaker implantation for asymptomatic children or adolescents with congenital third-degree AV block with acceptable rate, narrow QRS complex, and normal ventricular function 2, 3

Pacemaker implantation has been shown to improve long-term survival and prevent syncopal episodes in patients with congenital complete AV block, according to the American College of Cardiology 2
The American College of Cardiology recommends periodic evaluation of ventricular function after pacemaker implantation, as ventricular dysfunction may develop due to myocardial autoimmune disease or pacemaker-associated dyssynchrony 2
The American College of Cardiology notes that technical considerations for pediatric patients include the risk of paradoxical embolism due to thrombus formation on endocardial leads and the choice of implantation technique to preserve vascular access at a young age 2, 4