Pacemaker

Ahmed Ellithy
Electrophysiology
Rationale for Cardiac Pacing

• Cardiac pacing is a means of delivering an

electrical stimulus to the heart muscle to treat low
cardiac output state (LCOS) caused by an
arrhythmia. The aim of this treatment is to
optimize cardiac output.
 • Pulse generator
Artificial pacemaker • Leads
• Electrodes
Unipolar Vs Bipolar ∞ Single Vs Dual Vs Biventricular
 Types of pacemaker

Temporary
• Transcutaneous
• Transvenous (Endocardial)
• Epicardial
• Transesophageal
Permanent
• Epicardial
• Transvenous
Indications
Temporary Pacing Permanent Pacemaker
• second degree or third degree (complete • Second- or third-degree AV block with
heart block) symptomatic bradycardia
• As an adjunctive therapy to establish AV • Sinus node dysfunction with symptomatic
synchrony in postoperative arrhythmias bradycardia
• Overdrive pacing , such as atrial flutter and • An asymptomatic neonate with congenital
third-degree AV block
supraventricular tachycardia (SVT)
• Asymptomatic patients after cardiac surgery
• Any bradycardia with reduced cardiac output
with advanced second- or third-degree AV
• Support management of a patient prior to block
permanent pacemaker implantation
 1. Epicardial pacing

On/ Off
Rate
Emergency A Output
V Output
Lock/ unlock
 2. Transthoracic (non-invasive) pacing-Transcutaneous

Pad size according to weight

<25kg- pediatric pads --------- >25kg – adult pads

3. Transvenous
pacing
4. Transesophageal pacing
 On / Off
Rate
Emergency A Output

V Output
Lock/ unlock
Connect Pacing Wires

Potential

Fracture

Point
Pacemaker coding & modes

Temporary Pacemakers
I II III
Chamber Paced Chamber Sensed Response to Sensing
O = None O = None
A = Atrium A = Atrium I = Inhibited
V = Ventricle V = Ventricle T = Triggered
D = Dual D = Dual D = Triggered & Inhibited
Complications • Infection • Heart failure
• Hematoma • Pacemaker malfunction
• Venous thrombosis, • Cardiac arrest
embolism • Death (may be due to
• Pneumothorax surgery or failure of the
• Pectoral or pacemaker to correct
diaphragmatic muscle the underlying
stimulation from the condition)
pacemaker • Lead fracture
• Arrhythmias
• Cardiac tamponade
 • Pacemaker Spikes
Pacemakers • Sense >> detect intrinsic electrical activity
Rhythm • Pace >> Provide electrical stimulus
Interpretation • Capture >> Respond to pace
Assessing Pacemaker Function

• Determine the pacemaker's mode and settings

• Review the patient's 12-lead electrocardiogram (ECG)
• Select a monitoring lead that clearly shows the pacemaker spikes
• Determine the heart rate
• Assess the patient for any symptoms of decreased cardiac output
• Look for information that tells you which chamber is paced, and review the
strip:
• Is there capture? o Is there a P wave or QRS complex after each atrial or ventricular
spike?
• Are P waves and QRS complexes coming from intrinsic activity?
• If intrinsic activity is present, does the pacemaker respond appropriately?
 Assess

Sense

Failure
to
Captur
Pace
e
Failure to?
Failure to?
Failure to?
 FAILURE TO PACE: unable to pace patient despite appropriate pacemaker settings
Signs & Symptoms Cause Management

Electrode displacement (transvenous) Reposition patient, & reassess for pacing

CODE BLUE to be called. Emergency

management for loss of cardiac output .
Electrode displacement (epicardial) Trained medical officer or accredited PICU
RN to increase output to maximum setting
No pacing activity on pacemaker if wire still in patient.
Bradycardia
Hypotension Strip insulation & reinsert
Loss of consciousness Lead fracture
wire into cable or replace wire in Op Suite

Lead disconnection Reconnect lead

Fibrotic tip or oedema/scar tissue at Swap polarity of electrodes
electrode tip Increase output
Flat battery
Change pacemaker
Pacemaker malfunction
Electrolyte disturbance Correct Electrolytes
 FAILURE TO CAPTURE: when the pacemaker output fails to depolarise the myocardium
Signs & Symptoms Cause Management

Electrode displacement (transvenous) Reposition patient & reassess for capture

Low output setting Reassess threshold

No P-wave/QRS complex after
Increase in pacing threshold due to Swap polarity of electrodes
pacing spike
oedema/scar tissue or fibrosis at
Loss of atrial kick in Increase output
electrode tip
atriallypaced patients
Lead fracture Strip insulation & reinsert wire into cable
Bradycardia
Hypotension Lead disconnection Reconnect lead
Syncope Flat battery
Change pacemaker
Pacemaker malfunction
Myocardial perforation from Surgical emergency, treat haemodynamic
transvenous wire instability
Pacemaker sensing skeletal muscle
contraction
Stimulation of phrenic nerve by
Reposition patient & reassess for result
electrode tip (transvenous lead)
 UNDERSENSING: when the pacemaker fails to detect intrinsic cardiac depolarization
Signs & Symptoms Cause Management
Sensitivity too low (high mV number on Increase sensitivity (reduce mV
Pacing spike occurs prematurely or sensitivity dial) number on dial)
inappropriately Pacing spike may/may not Strip insulation & reinsert wire into
produce a QRS complex depending on where Lead fracture
cable
it occurs in the cardiac cycle Lead disconnection Reconnect lead
Palpitations, skipped beats Lethal arrhythmias
Battery depletion
can result Replace pacing box
Pacing box malfunction
from competition, or R-on-T
phenomenon Electromagnetic interference Identify & remove cause
Fixed rate pacing Reassess pacing modality
OVERSENSING: when the pacemaker detects non-cardiac electrical events
Signs & Symptoms Cause Management
Pacemaker sensing atrial or T wave activity
No pacing activity on ECG despite pacemaker
in patient’s intrinsic rhythm because
being set at higher pulse rate than patient’s
sensitivity level is not set at appropriate
intrinsic HR Adjust sensitivity level
level
Sense light flashing at higher rate than
Pacemaker sensing skeletal muscle
patient’s intrinsic pulse rate
contraction
 CHEST WALL OR DIAPHRAGMATIC STIMULATION:
Signs & Symptoms Cause Management

Hiccups Reassess threshold

Output too high
Muscle twitching Reduce output
Abdominal
Stimulation of phrenic
pain/discomfort Reposition patient &
nerve by electrode tip
reassess for result
(transvenous lead)
 Removal of epicardial pacing wires
• 1. Perform baseline vital signs and cardiac assessment and ensure patient is attached to a cardiac monitor
• 2. Print pre-wire removal rhythm strip from bedside monitoring
• 3. Perform hand hygiene and Don gloves
• 4. Remove any dressings from pacing wires
• 5. Clean wires and skin around puncture site with Aqueous Chlorhexidine 0.5% / 0.9% Sodium chloride
• 6. Cut suture holding the atrial wire
• 7. Place folded sterile gauze swab over atrial puncture site and wire and pull wire gently until it slides from the chest
• 8. Check the wire and wire tip are intact
• 9. Assess rhythm on cardiac monitor and assess patient
• 10. Assess chest tube drainage if applicable. If there is a sudden increase in drainage that does not resolve, contact
cardiothoracic team before removing ventricular wire.
• 11. If rhythm and patient is stable, repeat previous steps to remove ventricular wire
• 12. Cover pacing wire sites with appropriate dressings as necessary
• 13. Perform vital signs and patient cardiac assessment
• 14. Dispose of equipment appropriately
• 15. Print post-wire removal rhythm strip from bedside monitoring and paste both strips on appropriate form and placed
in patient notes.
• Alert: Be alert for tamponade acutely or slowly evolving. Notify cardiothoracic team and cardiology fellow (who
should perform immediate echocardiogram) if concerned
 • Maintain continuous cardiac monitoring, and monitor for
arrhythmias
• Administer medications as ordered
• Document the type of pacemaker inserted, lead system,
pacemaker mode, and pacing guidelines
• After the first 24 hours of permanent pacemaker insertion,
begin passive range-of-motion exercises on the affected arm if
ordered
Nursing • Monitor vital signs
Considerations • Monitor intake and output
• Assess for complications, such as abnormal bleeding and
infection
• Assess the surgical wound and dressing
• Monitor drainage
• Assess pacemaker function
Patient Teaching
• Possible complications and when to notify the physician (e.g. signs and symptoms of infection)
• Any diet or activity restrictions (including driving and return to work) as ordered by the physician
• How to monitor the heart rate and rhythm
• The patient should avoid placing excessive pressure over the insertion site, pushing or pulling objects, lifting
objects greater than 10 pounds, or extending his/her arms over his/her head for four to six weeks after discharge
• Ensure there is a follow up appointment with the physician
• The physician should be notified if the patient experiences signs of pacemaker failure, such as palpitations, a fast
heart rate, a slow heart rate (5 to 10 beats less than the pacemaker's setting), dizziness, fainting, shortness of
breath, swollen ankles or feet, anxiety, forgetfulness, or confusion
• Medical personnel need to be informed of the implanted pacemaker before undergoing certain diagnostic tests
• Provide the patient with an identification card that includes:
• o The pacemaker type and manufacturer o Serial number o Pacemaker rate setting o Date implanted o Physician’s
name