Pacemakers and Implantable Cardioverter Defibrillators History C. Lillehei & E.

Bakken produced first battery operated Pacemaker in 195

!illiam "reatbatch# cardiolo$ist in %e& 'orkfirst implantable pacemaker "eneral description of Pacemaker Consists of impulse $enerators and leads to sense and conduct impulses Leadsunipolar( bipolar( multipolar & trans)enous( epicardial *nipolar leadmetal case of the $enerator becomes second electrode *nipolar leads more sensiti)e to E+, # re-uire more ener$y# and ha)e lar$er spikes on the EC" than bipolar# therefore less common "eneric pacemaker code .%/0PE(BPE"1 Position , chamber paced2 3 none ( / 3 atrium ( 4 3 )entricle ( 5 3 dual ./641 Position ,,chamber sensed 2 3 none ( / 3 atrium ( 4 3 )entricle ( 5 3 dual ./641 Position ,,,response to sensin$ 2 3 none ( , 3 inhibited ( 7 3 tri$$ered ( 5 3 5ual 7ri$$eredpacin$ de)ice emits pulse only in response to a sensed e)ent ,nhibitedpacin$ inhibited by appropriate electrical acti)ity Position ,4pro$rammability 2 3 none ( P 3 pro$rammable ( + 3 +ulti pro$rammable ( C 3 Communicatin$ ( 8 3 rate modulation Position 4anti tachycardia functions none 3 2 ( P 3 Pacin$ ( 0 3 shock ( 5 3 dual .P601 Pacemaker parameters Pro$ram rate .pacin$ rate ( lo&er rate1lo&est rate at &hich the pacemaker &ill fire Hysteresis ,n patients &ith intrinsic acti)ity# hysteresis preser)es battery life ,ntrinsic acti)ity causes the pacemaker to fire the ne9t impulse at the hysteresis rate .&hich is lo&er than the pro$rammable rate1 Can mimic pacemaker dysfunction Circadian rate Lo&er rates durin$ certain times of the day# &hen cardio)ascular demands are lessbattery sa)in$ ad)anta$e Pulse amplitude and &idth Pulse amplitude set to :.5 ; < times the min )olta$e re-uired for myocardial depolari=ation /uto captureautomatically determines the desired suprama9imal )olta$e re-uired for depolarisation 0ensiti)itythreshold for detection of intrinsic e)ents /4 delay 5elay after atrial impulse after &hich the )entricle is paced by dual chamber pacers 8ate adapti)e delay)ariable delay &ith increasin$ or decreasin$ heart rate *pper trackin$ rate ,n atrial trackin$ mode)entricle paced accordin$ to atrial acti)ity ,f atrial acti)ity > . e.$. /?1 then pacemaker introduces second de$ree /4 block or ceases to sense atrial acti)ity &hen the preset upper trackin$ rate is reached

Pacemakers

8ate modulation Help > &ork capacity of indi)idual 7emporarily > pro$rammed rate &ith appropriate inputs ,nputs for rate modulation +inute )entilation .only one currently a)ailable# rest are under in)esti$ation1 8i$ht )entricular stroke )olume 84 pressure Blood temperature @A7 inter)al +i9ed )enous saturation Blood pH Pace maker indications Class , Complete heart block &ith symptomatic bradycardia CHB &ith CC? 0econd de$ree /4 block &ith symptomatic bradycardia /systole period B< sec ( escape rhythm CDE bpm e)en if asymptomatic 0econd de$ree /4 block ( bi fascicular block follo&in$ /cute +, 0inus node dysfunction &ith symptomatic bradycardia Class ,, CHB# asymptomatic# escape rhythmBDE bpm /symptomatic second de$ree /4 block 0inus node dysfunction &ith H8 C DE but symptoms not conclusi)ely linked to bradycardia Class ,,, ?irst de$ree /4 block /symptomatic sinus node dysfunction# &ith bradycardia due to dru$ therapy Preanaesthetic e)aluation and pacemaker 8epro$rammin$ 5etermine indication for and date of implantation 5etermine last $enerator test and battery status 5e)ice interro$ationobtain current pro$ram information Ensure $enerator impulses become mechanical systoles 5etermine &hether pro$rammin$ mode should be repro$rammed dependin$ upon sur$ery planned ,ntraoperati)e .procedural1 mana$ement /)oid filterin$ of pacemaker impulse on the EC" monitor E0C monopolar more interference than bipolar Feep return current pad as far a&ay as possible from the $enerator *se lo&est current and shortest burst of E0C Place leads for ner)e stimulator a&ay from $enerators +a$net placement .after consultation &ith manufacturer1 &ill attenuate aberrant beha)ior +8, absolutely contraindicated Chan$e to non sensin$ .asynchronous1 mode durin$ EC7 Pacemaker failure 5epends on haemodynamic picture 7emporary pacin$ trans)enous# trans thoracic# or )ia pacin$ pulmonary artery catheter

7rans oesopha$eal pacin$ if functional /4 node and atria present 0ympathomimetic dru$s to G depolarisation threshold .ephedrine# dopamine in usual doses1 Correct electrolyte# acid base imbalance# P2:# PC2:# anti arrhythmic dru$ le)els Post anaesthesia pacemaker e)aluation ,f repro$rammed for the perioperati)e period# then should be reset Ensure proper functionin$# assess remainin$ battery life Preanaesthetic e)aluation of ,C5 ,ntraoperati)e .procedural1 mana$ement Post anaesthesia ,C5 e)aluation

,mplantable Cardio)erter 5efibrillator indications