PERMANENT PACEMAKER

Name: Naved Sheikh

Lecturer
Dept. of CVT
Malla Reddy University
• A Permanent pacemaker (PPM) is a small device that is inserted under the skin of
the chest to maintain a regular rhythm.
 Equipment
• Equipment required for permanent pacemaker includes the following:
1. Fluoroscopy
2. Pacemaker device
3. Pacing lead
4. Pacing system analyzer
5. Introducer kit
6. 1-2% lidocaine
7. Antimicrobial flush and saline for pocket irrigation
8. Suture material (dexon)
9. Instrument tray
10. Emergency crash cart with medications
11. External defibrillator
Medicactions
• Routinely, cefazolin 1 g or patient weight-based dosing is
administered intravenously (IV) 1 hour before the procedure.

• If the patient is allergic to penicillins, vancomycin 1 g IV is

administered preoperatively.
Venous access
• A vein (subclavian vein) is accessed via a percutaneous approach.

• It can be technically difficult because skeletal landmarks are deviated,

so a brief fluoroscopic examination will help to reduce the time and
complications
• The subclavian vein is typically accessed at the junction of the first rib and the
clavicle.

• sometimes, phlebography may be required to visualize the vein adequately or

to confirm its patency.
• After venous access is obtained, a guide wire is advanced through the needle,
and the tip of the guide wire is positioned in the right atrium under
fluoroscopy.

• The needle is then withdrawn, leaving the guide wire in place.

• If indicated, a second access will be obtained in a similar fashion for positioning

of a second guide wire.

• Sometimes, a double-wire technique is used, whereby 2 guide wires are

inserted through the first sheath and the sheath then withdrawn.
Creation of pocket
• A 1.5- to 2-inch incision is made in the infraclavicular area parallel to
the middle third of the clavicle, and a subcutaneous pocket is created
where the pacemaker generator will be implanted.

• Some physicians prefer to make the pocket first and obtain access later
through the pocket or via venous cutdown; once access is obtained,
they position the guide wires as described above.
 Placement of leads
• Over the guide wire, a special peel-away sheath and dilator are advanced.
• The guide wire and dilator are withdrawn, leaving the sheath in place.
• A stylet (a thin wire) is inserted inside the center channel of the pacemaker lead to make it
more rigid, and the lead-stylet combination is then inserted into the sheath and advanced
under fluoroscopy to the appropriate heart chamber.
• Usually, the ventricular lead is positioned before the atrial lead to prevent its dislodgment.
• Making a small curve at the tip of the stylet makes the ventricular lead
tip more maneuverable, so that it can more easily be placed across the
tricuspid valve and positioned at the right ventricular apex.
• Once correct lead positioning is confirmed, the lead is affixed to the
endocardium either passively with tines (like a grappling hook) or actively via a
helical screw located at the tip.
Active and passive leads
• Once the lead is secured in position, the introducing sheath is carefully peeled
away, leaving the lead in place.

• After the pacing lead stylet is removed, pacing and sensing thresholds and lead
impedances are measured with a pacing system analyzer, and pacing is
performed at 10 V to make sure that it is not causing diaphragmatic stimulation.

• After confirmation of lead position and thresholds, the proximal end of the lead
is secured to the underlying tissue (ie, pectoralis) with a nonabsorbable suture
• If a second lead is indicated, it is positioned in the right atrium via a
second sheath, with the lead tip positioned in the RA appendage with
the help of a preformed J-shaped stylet.

• In a patient who is without an atrial appendage as a result of previous

cardiac surgery, the lead can be positioned medially or in the lateral
free wall of the right atrium.
 Positioning of pulse generator
• When the leads have been properly positioned and tested and sutured to the underlying tissue,
the pacemaker pocket is irrigated with antimicrobial solution, and the pulse generator is
connected securely to the leads.

• pulse generator is secured to underlying tissue with a nonabsorbable suture to prevent

migration or twiddler syndrome.

• Typically, the pacemaker is positioned superficial to the pectoralis

• After hemostasis is confirmed, a final look under fluoroscopy before closure of the incision is
recommended to confirm appropriate lead positioning.
 Completion and closure
• The incision is closed in layers with absorbable sutures.

• Sterile dressing is applied to the incision surface. An arm restraint or immobilizer is applied to
the arm for 12-24 hours to limit movement.

• A postoperative chest radiograph is usually obtained to confirm lead position and rule out
pneumothorax.

• Before discharge on the following day, postero-anterior and lateral chest radiographs will be
taken again to confirm lead positions and exclude delayed pneumothorax.
Suture after pacemaker implantation
PPI INDICATIONS
• Class I: These are conditions where implantation of a pacemaker is considered necessary and beneficial
(benefits much greater than risks).

• Class II: These are conditions where placement is indicated, but there is conflicting evidence or
divergence of opinion. In Class IIa weight of evidence is in favor of efficacy (benefits greater than
risk), while in class IIb, the efficacy is less well established (benefits ­greater than or equal to the risks).

• Class III: These are conditions in which permanent pacing is not recommended, and in some cases, it
may be harmful (risks greater than the benefits).
 SINUS NODE DYSFUNCTION (SND)
• CLASS- 1
• SND with documented symptomatic bradycardia including frequent sinus pauses that
produce symptoms.
• Symptomatic Chronotropic incompetency (inability of the heart to increase its rate during
exercise)
• Symptomatic sinus bradycardia that results from drug therapy for medical condition
• Class II a
• 1-SND with HR <40 bpm when a clear association between significant symptoms
consistent with bradycardia, and actual presence of the bradycardiya has not been
documented.
• 2- syncope of unexplained origin when clinically significant abnormality of sinus node
function are discovered or provoked in Electrophysiology studies (EP)
• CLASS II b- minimally symptomatic patient with chronic HR < 40 bpm in awake
• Class III

1. PPI is not indicated for SND in asymptomatic patient.

2. PPI is not indicated for SND in patient, for whom the symptoms suggestive of
bradycardia have been clearly documented to occur in the absence of the
bradycardia.

3. PPI is not indicated with symptomatic bradycardia, due to non essential drug therapy
 Acquired AV block
• CLASS 1

1. PPI is indicated for 3rd degree AV block and advance second degree AV block

2. Post operative AV block that is not expected to resolve after cardiac surgery.

3. Neuromscular disease with AV block such as Myotonic muscular dystrophy (genetic

disorder that causes progressive muscle weakness) Kearn's-sayre syndrome (rare genetic
disorder that affects the eyes, heart, and other parts of the body. It's caused by a defect in
the DNA of mitochondria) with or without symptoms.

4. PPI is indicated for 2nd degree or 3rd degree AV block during exercise in absence of the
myocardial ischemia.
• Class- II
• Neuromscular disease such as Myotonic muscular dystrophy, erb dystrophy with
any degree of AV block with or without symptoms, because there may be
unpredictable progression of the AV Conduction disease
 Hypotrophic cardiomapethy
• CLASS 1

• PPI is indicated for SND or AV block in patient with HCM

• CLASS II a- NONE

• CLASS II b-

• PPI may be considered in medically refractory Symptomatic patient with HCM and
significant resting or provoke and LVOT obstruction

• CLASS III

• PPI is not indicated who are asymptomatic or whose symptoms are medically controlled

• PPI is not indicated for symptomatic patients without evidence of the LVOT obstruction
Post MI
• CLASS I
• Persistent and Symptomatic 2nd degree or 3rd degree AV block

• CLASS II a- NONE

• CLASS II b
• Persistent 2nd degree or 3rd degree AV block even in the absence of the symptoms
 INDICATIONS
• Symptomatic Bradycardia: When the Heart beats too slowly and causes
symptoms like syncope, shortness of breath, fatigue, or chest pain due to
inadequate blood flow.

• Sinus Node Dysfunction : Dysfunction of the sinoatrial (SA) node, leading to an

irregular heartbeat or periods of slow heart rate alternating with fast heart rates.
• Atrioventricular (AV) Block: Specifically, a complete (third-degree) AV block, where
there's a complete interruption in the electrical conduction between the atria and ventricles.

• Tachy-Brady Syndrome: A condition where the heart alternates between too slow
(bradycardia) and too fast (tachycardia) rhythms, often requiring a pacemaker.

• Arrhythmias: In some cases, certain types of arrhythmias that cannot be controlled with
medication or other treatments may require pacemaker implantation to manage the heart rate
and rhythm.
 PACEMAKER CLASSIFICATION
• The North American Society of Pacing and Electrophysiology and the British
Pacing and Electrophysiology Group initially published a "pacemaker code" in
1983. Guidelines were later revised in 2002 and the five-position code remains the
accepted nomenclature for pacemaker therapy.
CLASSIFICATIONS OF NBG CODES
 The NBG code is a 5-letter code that describes exactly how a
pacemaker works:

• 1st letter: What the pacemaker is pacing (atrium, ventricle, or both).

• 2nd letter: What the pacemaker is sensing (atrium, ventricle, or both).

• 3rd letter: How the pacemaker responds to sensing (either triggers, inhibits, or both).

• 4th letter: Whether the pacing rate changes depending on activity (rate modulation).

• 5th letter: Whether multiple spots are paced in the heart (multisite pacing).

(This code helps doctors understand exactly how a pacemaker will behave and helps
them set it correctly for each patient’s needs)
•I = Inhibited: The pacemaker inhibits or stops stimulating the heart if it detects a natural
beat.
(This means it will not pace if the heart is already beating regularly on its own)

•T = Triggered: The pacemaker triggers or starts pacing when it detects that the heart has
missed a beat (for example, if the heart skips a beat).

•D = Dual: The pacemaker can both inhibit and trigger pacing based on the heart’s activity.
(It inhibits when the heart is beating normally and triggers when the heart misses a beat.)

•O = None: The pacemaker does not respond after sensing a beat.

 Here are a few examples of what the codes mean:

• VVI:
• V = Paces the ventricle
• V = Senses the ventricle
• I = Inhibits pacing if it senses a natural beat

• DDD:
• D = Paces both the atrium and ventricle
• D = Senses both the atrium and ventricle
• D = Can inhibit and trigger pacing as needed
• AAI:
• A = Paces the atrium
• A = Senses the atrium
• I = Inhibits pacing if it senses a natural beat

• DDDR:
• D = Paces both atrium and ventricle
• D = Senses both atrium and ventricle
• D = Inhibits and triggers pacing
• R = Rate-responsive, adjusts heart rate based on activity

• Why the NBG Code Matters:

• The NBG codes are important because they help doctors to choose the right
pacemaker settings for the patient. For example, if a patient needs help with
both atrium and ventricle pacing, a DDD pacemaker would be selected. If a
patient only needs help with the ventricle, a VVI might be more appropriate.
ATRIAL AND VENTRICULAR PACING
QUIZ
Here the ventricle is paced with no sensing and thus no response to sensing

Also called asynchronous pacing where the pacemaker will continuously depolarize at a
set pre-programed rate regardless of intrinsic activity

This is the default setting for all single chamber pacemakers

 LEAD THRESHOLD

• The Threshold refers to the minimum amount of electrical energy required to consistently
stimulate the heart muscle and cause a contraction.

• If the thresholds are too low, depolarisation will not be initialised, leading to inadequate
pacing resulting in symptoms like dizziness or fatigue.

• If the threshold are too high, the pacemaker battery will become depleted much quicker.
• Threshold levels includes voltage and pulse width.

• Voltage are measured in volts or millivolts (mV)

• The range for pacing thresholds can vary widely but is generally between 0.5 volts to
3.5 volts.

• The pulse width is the length of time each pacing pulse is delivered .

• The longer, the pulse width, the more energy being delivered.
Here we see paced beats at 1.75 volts
As we slowly decrease the voltage to 0.5 volts we no longer see ventricular contractions
75 volts was the amount of voltage needed to get a ventricular contraction – this is the threshold
 FACTORS AFFECTING LEAD THRESHOLD
• Lead Positioning: The placement of the pacing lead within the heart affects the
threshold.

• Correct positioning ensures effective electrical contact with the heart muscle, reducing
the required energy for pacing.
• Lead Integrity: Any damage or malfunction in the pacing lead can increase the threshold.

(Breaks or fractures in the lead wires makes transmission of electrical impulses more

difficult, requiring higher energy to stimulate the heart)

• Battery Voltage: As the battery in the pacemaker Depletes over time, the voltage it
delivers decreases.
Pacemaker lead fracture
 Physiology of cardiac pacing
• It refers to the process of artificially stimulating the heart's electrical conduction system to
maintain a regular rhythm by strategically placing a pacemaker lead within the heart
• ideally mimicking the natural electrical pathway of a healthy heart, aiming to preserve
ventricular synchrony and minimize negative effects on cardiac function
• This is achieved by targeting the His bundle or left bundle branch area, a technique known as
"physiological pacing.“

• Key points about cardiac pacing physiology:

• Natural conduction system:

• The heart's natural electrical pathway starts at the SA node, travels through AV node, then
down the bundle of His, which splits into the right and left bundle branches to activate the
ventricles.
• Goal of physiological pacing:

• Unlike traditional pacing methods that might stimulate the heart from a less optimal location, physiological
pacing strives to closely replicate the natural electrical activation sequence by placing the pacemaker lead
within the heart's intrinsic conduction system, like the His bundle or left bundle branch area.

• Benefits of physiological pacing:

• By stimulating the heart in a more natural way, physiological pacing can potentially minimize
complications like ventricular dyssynchrony, which can lead to impaired cardiac function, and improve
overall cardiac output.

• Cardiac resynchronization therapy (CRT):

• CRT is another strategy to improve ventricular synchrony by pacing both the right and left ventricles
simultaneously, often used in patients with heart failure.
CRT LEADS
 CARDIAC HEMODYNAMICS
• Heart Rate Regulation: A pacemaker monitors the heart's electrical activity. When it
detects irregularities or pauses in the heartbeat, it sends electrical impulses to
stimulate the heart muscles to contract, and thereby adequate blood flow throughout
the body, which is crucial for delivering oxygen and nutrients to tissues and
organs.

• Improving Cardiac Output: Cardiac output is the product of heart rate and stroke
volume. By regulating the heart rate, a pacemaker can improve cardiac output.
• Maintaining Blood Pressure: a pacemaker helps to maintain a stable blood
pressure by ensuring an adequate cardiac output and a consistent heart rate.

• Prevention of Heart Failure: Pacemakers can prevent complications like heart

failure by ensuring that the heart functions optimally.

• By regulating the heart's rhythm, pacemaker reduces the strain on the heart and
improve its efficiency, thereby decreasing the risk of heart failure.