Cardiac pacing for beginners

Resident Phattarasit

Clinical objectives
Define pacemaker Differentiate types of pacemaker List function of pacemaker Complication management

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First pacemaker

Arne Larsson

Class I Indications for Permanent Pacing in Adults (AHA/ACC)

1. Third-degree AV block at any anatomic level associated with any of the following Symptomatic bradycardia presumed secondary
to AV block

Symptomatic bradycardia secondary to drugs

required for dysrhythmia management or other medical condition Documented periods of asystole lasting more than 3 seconds or an escape rate of less than 40 beats/min in an awake, asymptomatic patient

Class I Indications for Permanent Pacing in Adults (AHA/ACC)

1. Third-degree AV block at any anatomic level associated with any of the following
After catheter ablation of the AV node Postoperative AV block that is not expected to resolve Neuromuscular disease with AV block (e.g., the muscular dystrophies)

Class I Indications for Permanent Pacing in Adults (AHA/ACC)

2. Symptomatic bradycardia resulting from second-degree AV block regardless of type or site of block

Class I Indications for Permanent Pacing in Adults (AHA/ACC)

3. Chronic bifascicular or trifascicular block with intermittent third-degree AV block or type II second-degree AV block

LAFB
rS rS

Far LAD (-30 to -90)

rS

qR

qR

LPFB

LPFB + RBBB (bifascicular block)

Class I Indications for Permanent Pacing in Adults (AHA/ACC)

4. After acute myocardial infarction with any of the following conditions:
Persistent second-degree AV block at the HisPurkinje level with bilateral bundle branch block or third-degree AV block at the level of or below the His-Purkinje system Transient second- or third-degree infranodal AV block and associated bundle branch block Symptomatic, persistent second- or third-degree AV block

Class I Indications for Permanent Pacing in Adults (AHA/ACC)

5. Sinus node dysfunction with symptomatic bradycardia (including sinus pauses) or chronotropic incompetence

Class I Indications for Permanent Pacing in Adults (AHA/ACC)

6. Recurrent syncope caused by carotid sinus stimulation

Clinical Indication
1. Symptomatic bradycardia 2. Symptomatic heart block
2nd degree heart block 3rd or complete heart block Bifasicular or trifasicular bundle branch blocks.

3. Prophylaxis

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Pacemaker Components
Pulse Generator (battery) Electronic Circuitry Lead system

Pulse Generator (battery)

In permanent pacemaker is encapsulated in a metal can ,to protect the generator from electromagnetic interference

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PaPulse Generator (battery)cemaker Design

Temporary pacing system generator is externally contained in a small box

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Pulse Generator (battery)

Transcutanus external pacing system house the generator in a piece of equipment similar to portable ECG monitor.

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Pulse Generator
Lithium-iodine cell is the current standard battery Advantages:
Long life 4 to 10 years Output voltage decreases gradually with time making sudden battery failure unlikely

Electronic Circuitry
Determines the function of the pacemaker itself Utilizes a standard nomenclature for describing pacemakers

Pacemaker Terminology
I
Chamber Paced
A=Atrium

II
Chamber Sensed
A=Atrium

III
Response to Sensing
T=Triggered

IV
Rate Modulation, Programmability
P=Simple M=Multiprogrammable R=Rate Adaptive C=Communicating O=None

V
Antitachycardia Features
P=Pacing S=Shock D=Dual

V=Ventricle V=Ventricle I=Inhibited D=Dual O=None D=Dual O=None D=Dual O=None

Common Permanent Pacemakers

Lead Systems
Endocardial leads which are inserted using a subclavian vein approach Actively fixed to the endocardium using screws or tines Unipolar or bipolar leads

Apex

Apex

Pacemaker function
1. Pacing function 2. Sensing function 3. Capture function

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Pacing function
Atrial pacing: stimulation of RT atrium produce spic on ECG preceding P wave

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Pacing function
Ventricle pacing : stimulation of RT or LT ventricle produce a spic on ECG preceding QRS complex.

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Electrocardiogram During Cardiac Pacing

VVI- senses intrinsic cardiac activity in the ventricle and when a preset interval of time with no ventricular activity occurs it depolarizes the right ventricle causing ventricular contraction

Pacer spike

Pacing function
AVpacing: direct stimulation of RT atrium and either ventricles mimic normal heart conduction

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Atrial Spike

Ventricular Spike

AV Pacing

Ventricular Pacin

DDD

DDD

Sensing function
Sensing : Ability of the cardiac pace maker to see intrinsic cardiac activity when it occurs.

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Sensing function
Demand: pacing stimulation delivered only if the heart rate falls below the preset limit. Fixed: no ability to sense. constantly delivers the preset stimulus at preset rate. Triggered: delivers stimuli in response to (sensing )cardiac event.
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Capture function
Capture: Ability of the pacemaker to generate a response from the heart (contraction) after electrical stimulation.

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Capture function
1. Electrical capture : indicated by P or QRS following and corresponding to a pacemaker spike. 2. Mechanical capture: palpable pulse corresponding to the electrical event.

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Pacing types
Permanent Temporary biventricular

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Types of pacing
1. Permanent pacemaker Used to treat chronic heart condition Surgically placed transvenuosly under local anesthesia Pulse generator placed in a pocket subcutaneously ,can be adjusted externally

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Permanent pacemaker

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Types of pacing
2. Temporary pacemaker Placed during emergencies Indicated for pts high degree heart block or unstable bradycardia Can be placed transvenosly, epicardially,transcutanusly or transthorasicly
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Types of pacing
3. Biventricular pacemaker Used in sever heart failure Utilize three leads in right atrium, right ventricle and left ventricle to coordinate ventricular coordination and improve cardiac out put
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INSERTION SITES
Left Subclavian (most reliable) Internal jugular (lower incidence of pneumothorax) Femoral vein Brachial vein

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Complications of Implantation

Complications of Implantation

Infections
Pacemaker insertion is a surgical procedure:
1% risk for bacteremia 2% risk for wound or pocket infection

Usually occur soon after pacer insertion Presence of a foreign body complicates management

Complications of Implantation

Infection
Cellulitis or pocket infection:
Tenderness and redness over the pacemaker itself Avoid performing a needle aspiration damage the pacer

Complications of Implantation

Infection
Bacteremia:
Staphylococcus aureus and Staphylococcus epi 60-70% of the time Empiric antibiotics should include vancomycin pending culture

Complications of Implantation

Infection
Consult the pacemaker physician Draw blood cultures Give appropriate antibiotics Frequently the pacer and lead system need to be removed

Complications of Implantation

Thrombophlebitis
venous obstruction : 30% 50%
axillary, subclavian, and innominate veins or the superior vena cava (SVC).

definitive diagnosis : duplex sonography, CT

Tx : heparin with long term warfarin

Complications of Implantation

The Pacemaker Syndrome

new complaints or report a worsening of the symptoms syncope or near-syncope orthostatic dizziness fatigue exercise intolerance weakness

Complications of Implantation

The Pacemaker Syndrome

lethargy chest fullness or pain cough uncomfortable pulsations in the neck or abdomen right upper quadrant painother nonspecific symptoms

Complications of Implantation

The Pacemaker Syndrome

loss of AV synchrony (VVI) If sinus node function is intact atrial contract when the tricuspid and mitral valves are closed jugular and pulmonary venous pressures and may produce symptoms of congestive heart failure. Atrial distention can result Elevated levels of B-type natriuretic peptide (BNP)

VVI

Pacer spike

Complications of Implantation

The Pacemaker Syndrome

Complications of Implantation

The Pacemaker Syndrome

Consultation with a cardiologist Change VVI to DDI

Magnet Placement
The EKG technician should perform a 12 lead cardiogram and then a rhythm strip with a magnet over the pacer Does not inactivate the pacer as is commonly believed Activate a lead switch present in the pacemaker which converts the pacer to a asynchronous or fixedrate pacing mode Inhibits the sensing function of a pacemaker Magnets are usually manufacturer specific, as are available external reprogramming devices

Complications of Implantation

Pacemaker Malfunction
Failure to capture Undersensing Oversensing Inappropriate rate

Complications of Implantation

Failure to capture
Lead disconnection, break, or displacement Exit block (failure of an adequate stimulus to depolarize the paced chamber) Battery depletion

Complications of Implantation

Failure to capture

Complications of Implantation

Failure to capture
Exit block (failure of an adequate stimulus to depolarize the paced chamber)
ischemia or infarction of the endocardium systemic hyperkalemia class III antiarrhythmic drugs, such as amiodarone

Complications of Implantation

Undersensing
Lead displacement Inadequate endocardial lead contact Low-voltage intracardiac p waves and QRS complexes Lead fracture

Complications of Implantation

Undersensing

Complications of Implantation

Failure to capture

Complications of Implantation

Oversensing
Sensing extracardiac signals: myopotentials T wave sensing Electromagnetic interference
digital cellular phone

Complications of Implantation

Oversensing

Complications of Implantation

Inappropriate Pacemaker Rate

Battery depletion Ventriculoatrial conduction with pacemakermediated tachycardia 1:1 response to atrial dysrhythmias (atrial flutter)

magnet application usually converts the pacemaker to a fixed rate in a competitive mode and terminates the tachyarrhythmia.

Management
History & Physical Examination
pacemaker identification card pacemaker malfunction present : syncope, nearsyncope, orthostatic dizziness, lightheadedness, dyspnea, or palpitations. wound infection or pocket infection typically arises with localized pain pacemaker syndrome

Management
Chest Radiograph : PA, lateral
define pacing catheter tip position and to determine the number of pacing leads

12-Lead Electrocardiogram Consult cariologist

Management
Electrical defibrillation : safe distance (10 cm) from the pulse generator (8 cm ACLS 2010 ) Immediate return of pacing (capture) may not occur after defibrillation Temporary transcutaneous pacing

Case 1
67 year old male presents to the emergency room 12 hours after insertion of a pacemaker complaining of left sided chest pain and shortness of breath PR 96 /min , RR 33 /min, BP 125/85, Oxygen saturation 88% RA CXR as shown

Pneumothorax
Occurs during cannulation of the subclavian vien Incidence - ?? Cardiologist dependent Treatment:
Asymptomatic or small observation Symptomatic or large tube thoracostomy

Notify the pacemaker physician

Case 2
72 year old male presents to the emergency room after a fall, tripped over a bath mat, no LOC Shortened and rotated left leg Past history pacemaker, hypertension Nurse does an routine pre-op CXR and EKG

Septal Perforation
Usually identified at the time of pacer insertion but leads can displace after insertion Can occur with transvenous pacer insertion Keys diagnosis are a RBBB pattern on EKG and a pacer lead displaced to the apex of the heart on CXR

Septal Perforation
Management:
Notify the pacer service Pacer wire has to be removed but not emergently Small VSD which heals spontaneously

Conclusions
Pacemakers are becoming more common everyday We need to understand basic pacing terminology and modes to treat patients effectively. Most pacer malfunctions are due to failure to sense, failure to capture, over-sensing, or inappropriate rate Standard ACLS protocols apply to all unstable patients with pacemakers.

Thank you