Basic Cardiac Pacing

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Anatomy Conduction System ECG Pacemaker Codes & Modes Pacemaker Indication
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The Heart
Muscular pump at the center of the circulatory system. Base Average dimensions: 13 x 9 x 6 cm Apex Weight: 300 grams

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Where is it ?
right lung
left lung diaphragm

sternum

vertebral column

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What is it made of?

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How is it structured?
Right Atrium Left Atrium

Atria
Left Ventricle Coronary Sinus Trabeculae Carnae Interventricular Septum ETC 05/99

Ventricles
Right Ventricle

How does it work?

Pulmonary Circulation
Head & Arms

Systemic Circulation
Head & Arms

Right Lung

Left Lung

Right Lung

Left Lung

Internal Organs Legs

Internal Organs Legs

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Four Chambers
Right Atrium Left Atrium

Mitral Valve Left Ventricle

Tricuspid Valve

Right Ventricle
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Atrioventricular / Semilunar Valves

Semilunar Valves

Pulmonary Valve

Aortic Valve

Tricuspide Valve

Mitral Valve

Atrioventricular Valves

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Atrioventricular / Semilunar Valves

Ventricular Relaxation (Diastole)
Aorta Left Atrium

Ventricular Contraction (Systole)

Aorta Left Atrium Aortic Valve Left Ventricle

Aortic Valve

Left Ventricle

Mitral Valve

Mitral Valve

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Circulatory System : Right Side

Pulmonary Arteries

To Right Lung
Superior Vena Cava
(deoxygenated blood from Head & Arms)

To Left Lung

Pulmonary Valve Inferior Vena Cava

(deoxygenated blood from Legs & Internal organs)

Tricuspid Valve
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Circulatory System : Left Side

To Head & Arms Pulmonary Veins
(oxygenated blood from Lungs)

From Right Lung Aorta

From Left Lung

Mitral Valve Aortic Valve To Body

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The passage of blood through the heart

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Cardiac Output
Cardiac output = Amount of blood pumped by the heart per minute Cardiac output = Heart rate x Stroke Volume
beats per minute
Slow
Fast

amount of blood per beat

Shorter strokes Longer strokes

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The Autonomic Nervous System

Controls and regulates the heart and other internal organs It is composed of two sets of nerves:

Sympathetic Nervous System Prepares the body for action (e.g., heart rate increases)

Parasympathetic Nervous System

Prepares the body for inactivity (e.g., slows the heart rate)

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Anatomy Conduction System ECG Pacemaker Codes & Modes Pacemaker Indication
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Response of a cell (muscle or nerve) to a stimulus

Heart cells are charged or polarized in the resting state. Resting Polarized

When they are stimulated, they depolarize and contract + + + + +++ + + + Contraction + + Depolarization + + + + + +++ When the cell relaxes is said to be repolarized. Relaxation
+ + + + + + + +

Repolarization
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Conduction System
Bundle of His

Sino-Atrial (SA) Node

Right & Left Bundle Branches

Atrio-Ventricular (AV) Node Purkinje System

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Sino-Atrial (SA) Node Depolarization

Sino-Atrial Node

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Atrial Depolarization
Right Atrium Left Atrium

SA Node

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Atrio-Ventricular(AV) Node Depolarization

Atrio-Ventricular Node

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Ventricular Depolarization
Bundle of His

Right & Left Bundle Branch

Purkinje fibers

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Pacemaker Activity of Electrical Conduction System

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Anatomy Conduction System ECG Pacemaker Codes & Modes Pacemaker Indication
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Electrocardiogram (ECG)

The ECG measures the electrical changes that

take place in the heart during each heartbeat.

These changes are detected by placing

combinations of electrodes on the surface of the skin, and recording the voltage difference between them.

ECGs provide information on the hearts

condition and performance.

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ECG : The Three Lead Configuration

II I +

III

Time

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The ECG Lead Setup

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Time versus Rate

Time is expressed in milliseconds (msec)
Rate is expressed in Beats Per Minute (bpm or ppm) 1 minute = 60 sec = 60,000 msec 60,000 Time = 60,000 Rate =

Rate

Time
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ECG : P wave
Atrium
Electrical
Depolarization

Mechanical
Systole

(contraction)

Ventricle
Electrical Mechanical

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ECG : P-R segment

Atrium
Electrical Mechanical
Systole

(contraction)

Ventricle
Electrical Mechanical

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ECG : QRS complex

Atrium
Electrical
Repolarization

Mechanical
Dyastole

(relaxation)

Ventricle
Electrical
Depolarization

Mechanical
Systole

(contraction)

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ECG : ST segment
Atrium
Electrical Mechanical
Dyastole

(relaxation)

Ventricle
Electrical Mechanical
Systole

(contraction)

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ECG : T wave
Atrium
Electrical Mechanical
Dyastole

(relaxation)

Ventricle
Electrical
Repolarization

Mechanical
Dyastole

(relaxation)

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ECG : P-R and S-T Intervals

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Anatomy Conduction System ECG Pacemaker Codes & Modes Pacemaker Indication
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Pacemaker System
Pulse Generator Pacing Lead

PULSAR MAX

Right Atrium Right Ventricle

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Single Chamber Pacing

Atrial Pacing Ventricular Pacing

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Dual Chamber Pacing

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Dual Chamber Stimulation

Advantages AV Synchrony Variability of the pacing rate Increase of the cardiac output Improve quality of life

Results

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Pulse Generator
Battery

PULSAR MAX

Sensing Circuit

Pacing Circuit
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Lead Fixation

Passive Fixation tines

Passive Fixation wings

Active Fixation screw-in

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Lead Fixation

Trabeculae Carnae

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NASPE/BPEG Pacemaker Code

A four-letter code is generally used to identify the mode of operation

1 letter
Chamber(s) Paced O = None A = Atrium V = Ventricle

st

2 letter
Chamber(s) Sensed O = None A = Atrium V = Ventricle

nd

3 letter
Response to Sensing O = None T = Triggered I = Inhibited

rd

4 letter
Programmability & Rate modulation O = None P = Simple programmability M = Multi programmability C = Telemetry R = Rate Modulation

th

D = Dual (A + V) D = Dual (A + V) D = Dual (T + I)

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Common Pacemaker Modes

Pacing

Sensing

Response to Sensing

Programmability & Rate Response

O - Ventricular pacing - No sensing

- No response to sensing

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Common Pacemaker Modes

Pacing

Sensing

Response to Sensing

Programmability & Rate Response

V - Ventricular pacing - Ventricular sensing

- Inhibited when sensing a ventricular event

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Common Pacemaker Modes

Pacing

Sensing

Response to Sensing

Programmability & Rate Response

V - Ventricular pacing - Ventricular sensing

- Inhibited when sensing a ventricular event - Rate response capabilities

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Common Pacemaker Modes

Pacing

Sensing

Response to Sensing

Programmability & Rate Response

- Dual (Atrial & Ventricular) pacing - Dual (Atrial & Ventricular) sensing - Dual (Inhibited & Triggered) response to sensing

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Common Pacemaker Modes

Pacing

Sensing

Response to Sensing

Programmability & Rate Response

- Dual (Atrial & Ventricular) pacing - Dual (Atrial & Ventricular) sensing - Dual (Inhibited & Triggered) response to sensing - Rate Response Capabilities
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Anatomy Conduction System ECG Pacemaker Codes & Modes Pacemaker Indication
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Pacemaker Indications

Sinus Node Dysfunction (Sick Sinus Syndrome) Atrioventricular (AV) Block

Binodal disease (Sinus Node disease with AV

Block)

Chronic Atrial Fibrillation(AF) with AV Block

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Sinus Node dysfunction

SA Node

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Choice of Pacemaker Model

Diagnosis
Sinus Node Dysfunction

Optimal Mode AAI(R) DDD(R)

Unacceptable Mode VVI(R) VDD(R)

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Atrioventricular Block
AV Node

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Atrioventricular (AV) Block

AV Node

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Choice of Pacemaker Model

Diagnosis
Sinus Node Dysfunction

Optimal Mode
AAI(R) DDD(R)

Unacceptable Mode
VVI(R) VDD(R)

AV block

DDD VDD

AAI(R) DDI(R)

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Binodal Disease
SA Node AV Node

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Choice of Pacemaker Model

Diagnosis
Sinus Node Dysfunction AV block

Optimal Mode
AAI(R) DDD(R) DDD VDD

Unacceptable Mode
VVI(R) VDD(R) AAI(R) DDI(R)

Binodal Disease

DDD(R)

VVI(R) AAI(R) VDD(R)

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Chronic AF with AV Block

AV Node

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Choice of Pacemaker Model

Diagnosis
Sinus Node Dysfunction AV Block Binodal Disease

Optimal Mode
AAI(R) DDD(R) DDD VDD DDD(R)

Unacceptable Mode
VVI(R) VDD(R) AAI(R) DDI(R) VVI(R) AAI(R) VDD(R)

Chronic AF with AV Block

VVI(R)

AAI(R) DDD(R) VDD(R)

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Coffee Break !!!!!

Next : Video How to Implant a Pacemaker ?

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