Pacemakers and Implantable Cardioverter Defibrillators

1. Pacemakers and Implantable Cardioverter Defibrillators

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

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

12. 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

13. 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

14. Codes Describing Pacemaker Modes

15. DDD

16. Indications for Pacing for AV Block

17. Indications for Pacing for Sinus Node Dysfunction

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

20. Case #1 72 year old male with chronic atrial fibrillation of greater than 10 years� duration is admitted following a syncopal episode. A 2D echo shows LVEF 60%. Telemetry reveals atrial fibrillation with slow ventricular response and pauses of 4 to 7 seconds associated with lightheadedness. How would you proceed?

21. Case #1 72 year old male with chronic atrial fibrillation of greater than 10 years� duration is admitted following a syncopal episode. A 2D echo shows markedly dilated left atrium and LVEF 60%. Telemetry reveals atrial fibrillation with slow ventricular response and pauses of 4 to 6 seconds associated with near syncope. How would you proceed? Answer: Implant a ventricular rate responsive pacemaker

22. 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

23. Pacemaker � Magnet Application

24. 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

25. Intermittent Loss of Ventricular Capture

26. �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

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

28. Expanded Indications for Pacing Cardiac resynchronization therapy Hypertrophic cardiomyopathy Neurocardiogenic syncope? Long QT syndrome

29. Biventricular Pacing

30. 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

31. Heart Failure - LBBBDelayed Ventricular Activation

32. Heart FailureBifocal Ventricular Pacing

33. Bi-Ventricular Pacing

36. Baseline ECG

37. Bi-V Pace

38. Implantable Cardioverter Defibrillator (ICD)

39. ICD Implantation Secondary prevention: Prevention of SCD in patients with prior VF or sustained VT. Primary prevention: Prevention of SCD in individuals without a h/o VF or sustained VT.

40. Indications For ICD VF/sustained unstable VT not in the setting of a completely reversible cause. LVEF = 35%, CHF NYHA class II, III. Ischemic dilated cardiomyopathy, LVEF = 40%, NSVT and inducible sustained VT. Syncope, LV dysfunction, inducible sustained VT. High risk patients with: hypertrophic cardiomyopathy, LQT syndrome, RV dysplasia, Brugada syndrome

42. ACC/AHA/HRS 2008 Guidelines: Systolic Heart Failure - Cardiac Resynchronization Therapy (CRT) Recommendations LVEF = 35% QRS = 120 msec NYHA functional Class III or ambulatory Class IV Optimal medical therapy

43. �Typical Case� 58 year old male, CAD, prior MI 1 year ago, LVEF 28%, CHF NYHA class II, treated with a betablocker, ACE inhibitor and statin; ECG: Sinus rhythm, old anteroseptal MI, QRS 98 msec Question : For prevention of sudden cardiac death, you would suggest: A. Treating medically without device implantation B. Implanting an ICD C. Implanting an ICD with biventricular pacing capabilities (3 leads)

44. Typical Case Q: 60 year old female presents with a 1 year h/o non ischemic dilated cardiomyopathy, CHF NYHA class III despite maximum medical therapy, LVEF 20% and LBBB with QRS 170 msec. What device is indicated? A: Bi-Ventricular ICD

45. 1� Prevention of Sudden Cardiac Death: Clinical Device Algorithm If CAD: (ACE Inhibitors, Beta Blockers)

46. 1� Prevention: Clinical Device Algorithm If Non �Ischemic Dilated Cardiomyopathy:

47. Primary Prevention Trials: Overall Mortality Reduction With ICD