Pacing

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.

The Heart Has an Intrinsic Pacemaker

The heart generates electrical impulses that travel along a specialized conduction pathway This conduction process makes it possible for the heart to pump blood efficiently Remember the hearts anatomy & physiology???

During Conduction, an Impulse Begins in the Sinoatrial (SA) Node and Causes the Atria to Contract

Atria Sinoatrial (SA) Node

Ventricles

Atrioventricular (AV) Node

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

Diseased Heart Tissue May:

Prevent impulse generation in the SA node Inhibit impulse conduction

SA node

AV node

Pacemaker Components Combine with Body Tissue to Form a Complete Circuit

Pulse generator: power source or battery Leads or wires Cathode (negative electrode) Anode (positive electrode) Body tissue

Lead

IPG

Anode

Cathode

The Pulse Generator:

Contains a battery that provides the energy for sending electrical impulses to the heart Houses the circuitry that controls pacemaker operations

Circuitry

Battery

Leads Are Insulated Wires That:

Deliver electrical impulses from the pulse generator to the heart Sense cardiac depolarization

Lead

Types of Leads
Endocardial or transvenous leads Myocardial/Epicardial leads

Fixation Mechanisms: Passive fixation

The tines become lodged in the trabeculae (fibrous meshwork) of the heart

Active Fixation
The helix (or screw) extends into the endocardial tissue

Myocardial and Epicardial Leads

Leads applied directly to the heart
Fixation mechanisms include:
Epicardial stab-in Myocardial screw-in Suture-on

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

During Pacing, the Impulse:

Begins in the pulse generator Flows through the lead and the cathode () Stimulates the heart Returns to the anode (+)
Impulse onset

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

Anode Cathode Cathode

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 [Link] 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

Parameter Chambers Chambers Response to endogenous measured paced sensed

depolarization

Possible values

O = None A= Atrium V= Ventricle D = Dual (A + V)

O = None A= Atrium V= Ventricle D = Dual (A + V)

O = None

O = None

O = None P = Pace S= Shock D = Dual

I = Inhibited R = Rate response on T= Triggered D = Dual (I + T)

For external pulse generators only positions I, II & III apply.

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

Electro magnetic interference

Sources of EMI are found most commonly in Hospital Environments Sources of EMI that interfere with pacemaker operation include surgical/therapeutic equip. such as: Electrocautery Transthoracic defibrillation Extracorporeal shock-wave lithotripsy Therapeutic radiation

Electro magnetic interference

RF ablation TENS units MRI New technologies will continue to create new, unanticipated sources of EMI: Cellular phones & digital technology.

Electro magnetic interference

Sources of EMI are found more rarely in: Home, office, and shopping environments Industrial environments with very high electrical outputs Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission Engines or subway braking systems Airport radar

MEDTRONIC 5388
Dual Chambered Pacemaker

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 AAI

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

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.

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.

Problems with Pacemakers Failure to Sense

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

Example 1

The Alan E. Lindsay ECG Learning Center ; [Link]

Ventricular sensed, ventricular paced Consistent with VVI

Example 2

The Alan E. Lindsay ECG Learning Center ; [Link]

Atrial sensed, ventricular paced Consistent with DDD or VDD

Example 3

The Alan E. Lindsay ECG Learning Center ; [Link]

Atrial paced Consistent with AAI or DDD

Example 4

The Alan E. Lindsay ECG Learning Center ; [Link]

Failure to Pace

Example 5

The Alan E. Lindsay ECG Learning Center ; [Link]

Failure to Sense

Paced Rhythm Recognition

VVI / 60

Paced Rhythm Recognition

DDD / 60 / 120

Paced Rhythm Recognition

VVI / 60

Paced Rhythm Recognition

AAI / 60

Paced Rhythm Recognition

DDD / 60 / 120

Paced Rhythm Recognition

DDD / 60 / 120

Paced Rhythm Recognition

DDD / 60 / 120

Pacing systems Electrical concepts Stimulation thresholds Sensing Electromagnetic Interference (EMI) Rate response NASPE / BPEG Nomenclature

Summary of Basic Pacing Concepts Module

Thank you