Pacemaker Therapy
Attila Kónyi M.D., Ph.D
Heart Institute
University of Pécs
Pacemaker therapy
(CIED-Cardiac Implantable Electronic Devices)
• Temporary or permanent
• Temporary :
– transcutaneous (rare, only during
resustitation)
– transvenous (v. jugularis, subclavian or
femoralis vein)
– transoesophegeal (nowadays very rare)
– pull-back (during heart surgery)
History
• The first artificial pacemaker was designed and
built in 1950 by the Canadian electrical engineer,
John Hopps.
• It was not implanted into the body and relied on
external electrodes that had to be plugged into a
wall outlet.
• Patient could go only as far as the extension
cord and a power blackout was of constant
concern.
• In 1958 the first pacemaker was implanted into
the body which had a battery life of ~12 to 18
months.
• First ICD implantation: 1980
Implantation rate in Europe
Parts of Pacemaker
• Pulse generator.
• Produces impulses and houses the
electrical circuitry.
• Constructed of titanium and
contains a lithium battery with a life
of ~8 to 15 years
• The battery will provide a low
warning months before it has
fatigued.
• Generator sends out electrical
impulses through leads that are
attached to the myocardium.
Parts of Pacemaker
• Lead(s)
• Insulated wires that not only receive impulses, but
carry signals back from the heart to the generator.
• Lead(s) are steroid eluting to decrease the
inflammation of the interface between the distal tip
of the lead and myocardium.
Two types:
active (screw)- less disloc.,
easy extract
passive (anchor)- less perforation
NASPE- Code sytem
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• These codes designate the programmed mode of the device:
• - Position I : the chamber(s) paced:
– “A” stands for atrium, “V” for ventricle, “D” for pacing capability in both atrium and ventricle,
and O if the unit is deactivated without pacing.
• Position II : the chamber(s) sensed:
– O stands for asynchronous operation without sensing.
• Position III:
– the unit’s response to a sensed signal; I : Inhibition
– T: tiggered
– D: both
• Position IV: rate-modulation capability.
• Position V: multisite pacing:
– O: indicates no more than one site in each chamber paced;
– A indicates that more than one pacing is present in the atrium;
– V indicates that more than one pacing site is present in the ventricle;
– D indicates that more than one pacing site is present in the atrium and ventricle.
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• SSI Mode:
– The AAI and VVI modes act in a comparable manner, with pacing and sensing in the same
chamber (atrium or ventricle) and the pacing output is inhibited by a sensed event in that
chamber. For practical purposes, AAI and VVI modes may be considered to be a common
SSI mode.
• VVI Mode:
- In the VVI mode, the ventricular inhibited pacing mode, the pacemaker senses
and paces in the ventricle. This mode is most appropriate for patients in chronic
atrial fibrillation (AF) in whom atrial sensing or pacing is not needed
• V00 Mode:
– In the VOO mode, ventricular pacing without ventricular sensing is present No
intrinsic events are sensed, and therefore ventricular pacing occurs independent
of the intrinsic rhythm. VOO is programmed on to prevent EMI from resulting in
ventricular inhibition in the pacemaker-dependent patient.
Oversensing and Undersensing
• Oversensing: The PM senses an event that does not represent
ventricular depolarization.
• Possible causes: parts of the QRS complex, the T wave,
afterdepolarizations, atrial activity, noise, myopotencials,
electromagnetic interference (EMI)
T wave is sensed as „R” wave
Undersensing:
In undersensing: the pacemaker does not sense an intrinsic
ventricular depolarization (R wave)
The pacing interval will be shorter than the pacing cycle length
R wave not sensed
Hysteresis Rate
• Hysteresis: longer ventricular escape interval from the last
ventricular sensed event to the first ventricular paced event (R-V,
hysteresis interval) but no change in the time from the last
ventricular paced event
• allows the intrinsic heart rate to be lower before pacing occurs, but
when pacing occurs, it will occur at a faster rate.
• E.g.: if the hysteresis pacing rate is 50 beats per minute and the
base pacing rate is 60 bpm, pacing will not occur if the patient
continues to maintain rates above 50 bpm. When the heart rate falls
below 50 bpm, however, pacing will occur at 60 bpm.
Implantation procedure
• A small 5-10 cm incision
• Small pocket will be made under skin for
generator and lead(s).
• Under fluoroscopy, lead(s) travel through the
subclavian vein, brachiocephalic vein, superior
vena cava, and finally into the desired chamber.
• Hospitalization usually last 1 to 3 days.
Műtéti technika
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Alternatív műtéti technikák
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Adverse events: pneumothorax, bleeding,
hemopericardium, infection
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Milyen PM-t?
single chamber-
MRI compatible
dual chamber
special features AF monitoring, sleep apnoe
monitoring, minimal ventricular capture,
remote ambulatory monitoring
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Programmable parameters:
- basic rate
-lower limit
-upper limit
-night rate
-rate respons
-auto capture
-hysteresis
-mode switching
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Cardiac Resynchronisation Therapy (CRT)
-Heart failure + conduction delay ( LBBB)
-dyssynchrony: echo, MRI
-Impaired left ventricular function (EF« 35%)
CRT-P: No ICD function
CRT-D: with defibrillator function
3 leads: right atrium, right ventricle, left ventricle
(through CS)
- It can improve EF, less mortality rate, improved
clinical outcome, less hospitalisation because of
HF, better clinical condition (improved NYHA
class)
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Future perspectives
- Subcutaneous ICD
- Leadless PM
- Cardiac Contractility Modulator-
- Biological PM
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