Pacing Solutions for Immune Checkpoint Myocarditis and Associated Conduction Disorders

Myocarditis is a rare but serious immune-related adverse event associated with immune checkpoint inhibitors. Mortality from immune checkpoint inhibitor associated myocarditis (ICIMy) is high, and developing advanced atrioventricular block is associated with worse mortality. Among a single-center cohort of 103 patients diagnosed with ICIMy, we describe 9 patients who required cardiac pacing for complete heart block. We present our systematic approach to managing ICIMy with advanced atrioventricular block, emphasizing the use of an active fixation right ventricular lead and external pacemaker generator for temporary pacing. This allows for stable and prolonged temporary pacing over a period of 4 to 6 weeks before deciding on implantation of a permanent pacemaker. This strategy has the potential to minimize infection risk by avoiding the need for generator pocket formation while patients are undergoing immunosuppressive therapy for treatment of ICIMy and allows for patient mobility and participation in physical therapy.