Temporary and Permanent Cardiac Pacing

1. Temporary and Permanent Cardiac Pacing

2. Temporary and Permanent Cardiac Pacing Introduction Temporary pacing : Indications, Technique Permananent Pacing : Pacemaker Nomenclature Indications Selection of Pacing Mode Pacing for Hemodynamic Improvement Pacemaker Implantation, Complications Pacemaker Troubleshooting

3. Temporary Cardiac Pacing Transvenous Transcutaneous Epicardial Transesophageal

4. Indications for Temporary Pacing Acute myocardial infarction with: CHB, Mobitz type 2 AV block, medically refractory symptomatic bradycardia, alternating BBB, new bifascicular block, new BBB with anterior MI In absence of acute MI : SSS, CHB, Mobitz type 2 AV block Treatment of tachyarrhythmias : VT

5. Temporary Transvenous Pacing Unipolar Electrograms

6. Paced QRS Morphology

7. Permanent Pacing

8. The Pacemaker System Patient

9. Pacemaker Implantation Epicardial Transvenous : Generator implanted anterior to pectoral muscle Atrial/Ventricular leads via subclavian or cephalic vein Sensing and pacing threshold Chest X-ray for pneumothorax, lead position

11. Codes Describing Pacemaker Modes

12. DDD

13. Indications for Pacing for AV Block

14. Indications for Pacing for Sinus Node Dysfunction

16. Pacing for Hemodynamic Improvement Hypertrophic Obstructive Cardiomyopathy Cardiac Resynchronization Therapy

17. Evolving Indications for Pacing Long QT syndromes Sleep apnea Neurally mediated syncope

18. 18 Mode Selection Considerations Status of Atrial Rhythm - Intrinsic vs. Paced - Presence of Atrial Tachyarrhythmias: Acute/Chronic Status of AV Conduction Normal -Slowed-Blocked Presence of Chronotropic Incompetence 

19. Choice of Pacing Mode

20. Rate Responsive Pacing Goal: To provide an increased heart rate for the chronotropic incompetent patient The Pacemaker: Allows programming of a minimum rate and a maximum rate Is allowed to pace (in response to sensor input) at any rate in-between this min and max rate

21. Today’s Sensors Vibration non-physiologic Acceleration non-physiologic Minute Ventilation physiologic Temperature physiologic

22. Pacemaker Implantation

24. Sensing

25. Pacemaker Follow-up GOAL OF FOLLOW-UP Verify appropriate pacemaker operation Optimize pacemaker functions Document findings, changes and final settings in order to provide appropriate patient management

26. Dual Chamber Pacemaker

27. Pacemaker – Magnet Application

28. Pacemaker – Mode Switch ( 1 of 3 )

29. Mode Switching in a Dual Chamber Pacemaker ( 2 of 3 )

30. Mode Switching in a Dual Chamber Pacemaker ( 3 of 3 )

31. Acute Complications of Pacemaker Implantation Venous access Pneumothorax, hemothorax Air embolism Perforation of central vein Inadvertent arterial entry Lead placement Brady – tachyarrhythmia Perforation of heart, vein Damage to heart valve Generator Pocket hematoma Improper or inadequate connection of lead

32. Delayed Complications of Pacemaker Therapy Lead-related Thrombosis/embolization SVC obstruction Lead dislodgement Infection Lead failure Perforation, pericarditis Generator-related Pain Erosion, infection Migration Damage from radiation, electric shock Patient-related Twiddler syndrome

33. Pacemaker Troubleshooting Failure to capture – high threshold,lead dislodgement, conductor coil fracture Failure to pace ( failure to output ) – oversensing, circuit interruption, battery depletion Failure to sense – undersensing, oversensing

34. Intermittent Loss of Ventricular Capture

35. Myopotential Sensing

37. “Pacemaker Syndrome” Fatigue, dizziness, hypotension Caused by pacing the ventricle asynchronously, resulting in AV dissociation or VA conduction Mechanism: atrial contraction against a closed AV valve and release of atrial natriuretic peptide Worsened by increasing the ventricular pacing rate, relieved by lowering the pacing rate or upgrading to dual chamber system Therapy with fludrocortisone/volume expansion NOT helpful

38. Sources of Electromagnetic Interference Medical MRI Lithotripsy Electrocautery/cryosurgery External defibrillators Therapeutic radiation Nonmedical Arc welding equipment Automobile engines Radar Transmitters

39. Expanded Indications for Pacing Cardiac resynchronization therapy Hypertrophic cardiomyopathy Neurocardiogenic syncope Long QT syndrome Prevention of atrial fibrillation

40. Normal Conduction Is Important Normal conduction allows for prompt and synchronous activation of the atria and ventricles Results in a brief P wave, PR interval and a narrow QRS

41. Heart FailureDelayed Ventricular Activation

42. Heart FailureBifocal Ventricular Pacing

44. Bi-Ventricular Pacing

47. Baseline ECG

48. Bi-V Pace

49. ICD Indications for Primary Prevention of Sudden Cardiac Death

50. Indications For ICDs Secondary prevention of SCD: VF arrest, sustained VT not secondary to reversible cause Primary prevention of SCD: LVEF < 36%, class II-III symptoms of CHF CAD, h/o MI, LVEF = 40%, inducible sustained VT Familial or inherited conditions with high risk for SCD: HCM, long QT syndrome, Brugada syndrome

52. Primary Prevention of SCD/ICD Studies:

53. Primary Prevention Trials: Overall Mortality Reduction With ICD

54. ACC/AHA/ESC 2006 Guidelines for Management of Patients with Ventricular Arrhythmias & SCD – ICD Indications: Primary Prevention, CAD & LV dysfunction Class I: ICD recommended to reduce mortality by reduction in SCD in pts with LV dysfunction due to prior MI who are at least 40 days post-MI, LVEF = 30-40%, NYHA class II or III, & receiving chronic optimal medical therapy, and have reasonable expectation of survival with good functional status for > 1 yr (level evidence A) Class IIA: ICD reasonable in pts with LV dysfunction due to prior MI who are at least 40 days post-MI LVEF = 30-35%, NYHA class I on chronic optimal medical therapy, and have reasonable expectation of survival with good functional status for > 1 yr (level evidence B)

55. ACC/AHA/ESC 2006 Guidelines – Primary Prevention, Dilated CM (non-ischemic) Class I: ICD recommended to reduce mortality by reduction in SCD in pts with non-ischemic DCM, LVEF = 35%, NYHA class II or III, who are receiving chronic optimal medical therapy, and who have reasonable expectation of survival with good functional status for > 1 yr (level evidence B) Class IIa: ICD can be beneficial for pts with unexplained syncope, significant LV dysfunction, and non-ischemic DCM who are receiving chronic optimal medical therapy, and who have reasonable expectation of survival with good functional status for > 1 yr (level evidence C) Class IIb: ICD might be considered in pts who have non-ischemic DCM, LVEF = 30-35%, NYHA class I receiving chronic optimal medical therapy, and who have reasonable expectation of survival with good functional status for > 1 yr (level evidence C)

56. ACC/AHA/ESC 2006 Guidelines – Heart Failure – CRT recommendations Class IIa: ICD combined with BiV pacing can be effective for primary prevention to reduce mortality by reduction in SCD in pts with LVEF = 35%, NYHA class III or IV receiving optimal medical therapy, in SR with QRS complex = 120 ms who have reasonable expectation of survival with good functional status for > 1 yr (level evidence B)

57. “Typical Case” 58 year old male, CAD, prior MI, EF 28%, CHF, NYHA class III, Medications: Lasix 80 BID, Enalapril 20 BID, Aldactone 25 qd, Digoxin 0.125 qd, Coumadin 5 qd, Coreg 25 BID, no presyncope or syncope or VT, ECG: Sinus rhythm, anteroseptal MI, QRS 96 msec Question – Based on available trial data, you would suggest: A. Treating medically without device implantation B. Implanting an ICD (single chamber) C. Implanting an ICD with biventricular pacing capabilities (3 leads)

58. 1° Prevention of Sudden Cardiac Death: Clinical Device Algorithm If CAD: (ACE Inhibitors, Beta Blockers)

59. 1° Prevention: Clinical Device Algorithm If Non –Ischemic Dilated Cardiomyopathy: