Pacemakers

Outline
1.Energy calculation 2.Pacemaker codes 3.Pacemaker configurations 4.Indications for pacemakers 5.Problems with pacemakers 6.Examples 7.Battery 8.Recent trends 9.Leads and electrode

Implantable pacemakers
Fixed Rate Demand R-Wave triggered Ventricular inhibited Atrial triggered Dual chamber

Pacemakers

Energy Calculation

 Ep=(Vs2/RH) TD + VS IDT Ep - Energy delivered by the pacemaker to the heart during each pulse Vs Voltage RH Electrode heart resistance TD Pulse duration ID Drain current T- time period between successive pulse

Pacemaker Codes
Position Function 1 Chambers Paced 2 Chambers Sensed O 3 Response to Sensed Stimulus O 4 Rate Modulation? O (non-rate responsive)
R (rate responsive)

O (none)

A (atrium)

T (triggered)

V (ventricle)

I (inhibited)

D (both atrium & ventricle)

Pacemaker Configurations VOO

Indications Temporary mode some-times used during surgery to prevent interference from electrocautery

Pacemaker Configurations VVI

Indications The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation).

Pacemaker Configurations AAI

Indications Sick sinus syndrome in the absence of AV node disease or atrial fibrillation.

Pacemaker Configurations VDD

Indications AV block with intact sinus node function (particularly useful in congenital AV block).

Pacemaker Configurations DDD

Indications 1. The combination of AV block and SSS. 2. Patients with LV dysfunction and LV hypertrophy who need coordination of atrial and ventricular contractions to maintain adequate CO.

Indications for Pacemaker

Class I 1. Sinus node dysfunction with documented symptomatic bradycardia 2. Symptomatic chronotropic incompetence (failure to increase HR with exercise or increased metabolic demand) 3. 3 and advanced 2 AV block associated with any of the following: Arrhythmias that require drugs resulting in symptomatic bradycardia Sinus pauses > 3 seconds Asymptomatic escape rate < 40bpm while awake 4. 3 or 2 AV block with associated symptomatic bradycardia 5. Type II 2 AV block with wide QRS, regardless of symptoms

Indications for Pacemaker

Class IIa 1. Syncope of unexplained origin when major abnormalities of sinus node function are discovered or provoked during EP studies. 2. Asymptomatic 3 AV block with an awake ventricular rate > 40bpm 3. Asymptomatic type II 2 AV block

Problems with Pacemakers Failure to Capture

Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.

Causes:

Threshold rise (electrolytes, drugs) Lead dislodgement Lead fracture RV infarct

Problems with Pacemakers Failure to Pace

Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.

Causes:

Oversensing Battery failure Internal insulation failure Conductor coil fracture

Problems with Pacemakers Failure to Pace

Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.

Causes:

Crosstalk

Problems with Pacemakers Failure to Sense

Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.

Causes:

Undersensing Lead Fracture

Example 1

The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/

Ventricular sensed, ventricular paced Consistent with VVI

Example 2

The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/

Atrial sensed, ventricular paced Consistent with DDD or VDD

Example 3

The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/

Atrial paced Consistent with AAI or DDD

Example 4

The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/

Failure to Pace

Example 5

The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/

Failure to Sense

Pacemaker Battery
Mercury Batteries Biological power sources Nuclear batteries
o o

Plutonium 238 (Half life of 87 years) 2Li+I2= 2LiI+e

Lithium cells

 Battery energy in joule

(A-H Rating)* VS * 3600 (s/h) Joules

Life time of a battery

(battery energy in joule/Energy delivered in each pulse)* T Sec Life time * (1/3600)* (1/24) *(1/365) Years

Recent trends
Programmable Pacemakers Rate responsive

Leads and electrode

Myo cardial Outside wall Endo cardial inside wall
o o o o

Sutureless Tined Porous tip Steriod eluting