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Objectives
Indications for pacing. NASPE / BPEG nomenclature. Assessment / reassessment of patient.
Indications
Hemodynamically unstable bradycardia Systolic blood pressure < 80-90 Altered mental status AMI (chest pain, angina) CHF / Pulmonary edema Failure of pharmacologic therapy Risk of high degree A.V. block Bradyasystolic cardiac arrest Overdrive pacing (SVT, V tach)
. Contraindications
Rhythm misinterpretation Asystole mistaken as v-fib Severe hypothermia May precipitate v-fib. Correct temperature first Relative Contraindication Bradyasystolic arrest lasting longer than 20 minutes. Chance of success is low.
During Conduction, an Impulse Begins in the Sinoatrial (SA) Node and Causes the Atria to Contract
Ventricles
Then, the Impulse Moves to the Atrioventricular (AV) Node and Down the Bundle Branches, Which Causes the Ventricles to Contract
Atria SA node
Ventricles
AV node
Bundle branches
SA node
AV node
Lead
IPG
Anode
Cathode
Circuitry
Battery
Lead
Types of Leads
Endocardial or transvenous leads Myocardial/Epicardial leads
Active Fixation
The helix (or screw) extends into the endocardial tissue
Cathode
An electrode that is in contact with the heart tissue Negatively charged when electrical current is flowing
Anode
An electrode that receives the electrical impulse after depolarization of cardiac tissue Positively charged when electrical current is flowing
Anode Cathode
Conduction Pathways
Body tissues and fluids are part of the conduction pathway between the anode and cathode
Anode
Tissue
Cathode
Unipolar Pacing
Current Flows through the tip electrode (cathode) Stimulates the heart Returns through body fluid and tissue to the IPG (anode)
A Bipolar Pacing
Flows through the tip electrode located at the end of the lead wire Stimulates the heart Returns to the ring electrode above the lead tip
Anode
Single-Chamber System The pacing lead is implanted in the atrium or ventricle, depending on the chamber to be paced and sensed
Dual-Chamber Systems
Have Two Leads
One lead implanted in the atrium One lead implanted in the ventricle
METHODS OF PACING
Epicardial
Used in patients that have undergone open heart surgery. Temporary leads are placed on the epicardium during surgery and exit through the chest wall.
Transcutaneous
Pads are placed on the chest or on the chest and back of a patient and attached to an external pulse generator.
METHODS OF PACING
Implanted pulse generator
A small device is surgically placed in a subcutaneous pocket.
Transvenous
Via central line a lead is thread down to the RV.
Transcutaneous Pacing
Simple procedure Pacing pads Easy to apply Non invasive Most monitor-defibrillators are also pacers Can be one person procedure Pads to chest wall Attached to monitor-defibrillator Bridge until more permanent device can be inserted
Transvenous Pacing
Invasive Equipment intense Invasive Exposure to blood Requires at least 2 people Directly into heart Quick in hands of experienced practitioner Wire into Right Ventricle Attached to Pulse Generator
Types of pacemakers
Temporary
-Transvenous- pacing wire via central line to RV under X ray,usually bipolar i.e. with 2 electrodes at the end of wire -Transthoracic-one electrode over cardiac apex,other over right scapula or clavicle -Epicardial Pacing
Permanent a pulse generator is implanted subcutaneously,electr odes usually unipolar i.e.one intracardiac electrode,with current returning to pacemaker via body
Pacemaker Configurations
NASPE, North American Society of Pacing and Electrophysiology; BPEG, British Pacing and Electrophysiology Group
Position
II
III
IV
Rate modulation
V
Anti tachycardia function
Possible values
O = None
O = None
Terminology
Atrial Tracking A pacing mode in which the ventricles are paced in synchrony with sensed atrial events. A-V Synchrony The activation sequence of the heart in which the atria contract first and then, after an appropriate delay, the ventricles. Base Rate The rate at which a pulse generator emits a stimuli.
Terminology
Dual Chamber Pacing Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heart. Overdrive pacing Pacing the heart at a rate faster than the patients intrinsic rhythm: to suppress a tachycardia, to gain electrical control of the heart, or to suppress PVCs
Terminology
Asynchronous Pacemaker which stimulates at a fixed, preset rate independently of the electrical or mechanical activity of the heart. Demand (inhibited) Any pacemaker which, after sensing a spontaneous depolarization, withholds a pacing stimulus. A-V Sequential A dual chamber pacemaker which can pace and sense in both atria &
Terminology
Tracking Pacemaker behavior in which ventricular pacing is synchronized to sensed atrial activity. Triggered The opposite of inhibited (demand). A triggered pacemaker, upon detecting a spontaneous depolarization or other signal, will deliver an electrical stimulus to the heart.
Pacing
The primary role of cardiac pacing is to augment or replace the heart's intrinsic electrical system.
Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias.
Most modern units are Dual units,working in DDD mode, providing atrial pacing in presence of atrial bradycardia & ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent. Worldwide, > 250,000 permanent cardiac pacemakers implanted each year. As the population ages and as indications for pacemakers expand, the number of implants continues to
increase
Pacemaker Programmer
The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider. The pacemaker programmer is used to perform a multitude of functions, including assessing battery status, modifying pacemaker settings, and providing access to diagnostic information the pacemaker has stored (e.g., heart rate trends and tachyarrhythmia documentation
Assessment
Check monitor Check PULSE Check responsiveness Check BP Obtain 12 lead EKG Document pacer settings
Assessment
Post Transvenous Insertion Secure catheter Usually sutured by the physician Apply sterile dressing Secure pacing leads by looping them and taping them outside the dressing Secure generator to patient Obtain CXR to verify lead placement and evaluate for pneumothorax.
Assessment
Detailed examination of cardiovascular system Identification of pacemaker,determination of pacemaker mode,primary indication for pacing Details of when device implanted,when & where it was last checked, anatomical position of current active generator Pulse generator- battery status,reset mode, information & confirmation of satisfactory thresholds
Assessment
12 lead ECG (1) All beats preceeded by a pacemaker spike:assume patient is pacemaker dependent (2) If native rhythm predominates-not pacemaker dependent (3) If pacemaker spike not followed by P or QRS suspect pacemaker malfunction
Complications
Hemo/pneumothorax during insertion Bleeding at insertion site Myocardial perforation Myocardial irritability >> dysrhythmias Transient BBB Failure to achieve capture
MEDTRONIC 5388
Dual Chambered Pacemaker
Indications Temporary mode some-times used during surgery to prevent interference from electrocautery
Indications The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation).
Indications Sick sinus syndrome in the absence of AV node disease or atrial fibrillation.
Indications Sick sinus syndrome in the absence of AV node disease or atrial fibrillation.
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.
Causes:
Example 1
Example 2
Example 3
Example 4
Failure to Pace
Example 5
Failure to Sense
VVI / 60
DDD / 60 / 120
VVI / 60
AAI / 60
DDD / 60 / 120
DDD / 60 / 120
DDD / 60 / 120
Pacing systems Electrical concepts Stimulation thresholds Sensing Electromagnetic Interference (EMI) Rate response NASPE / BPEG Nomenclature
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