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Pacing
Objectives
bull Indications for pacingbull NASPE BPEG nomenclaturebull Assessment reassessment of patient
Indications
bull Hemodynamically unstable bradycardiabull ndash Systolic blood pressure lt 80-90bull ndash Altered mental statusbull ndash AMI (chest pain angina)bull ndash CHF Pulmonary edemabull Failure of pharmacologic therapybull Risk of high degree AV blockbull Bradyasystolic cardiac arrestbull Overdrive pacing (SVT V tach)
Contraindications
bull Rhythm misinterpretationbull ndash Asystole mistaken as v-fibbull Severe hypothermiabull ndash May precipitate v-fib Correct temperature firstbull Relative Contraindicationbull ndash Bradyasystolic arrest lasting longer than 20bull minutes Chance of success is low
The Heart Has an Intrinsic Pacemaker
bull The heart generates electrical impulses thatbull travel along a specialized conduction pathwaybull This conduction process makes it possible forbull the heart to pump blood efficientlybull Remember the heartrsquos anatomy ampbull physiology
Ventricles
Sinoatrial (SA) Node
Atrioventricular (AV) Node
Atria
During Conduction an Impulse Begins in the Sinoatrial (SA) Node and Causes the Atria to
Contract
Atria
Ventricles
Bundle branches
AV node
SA node
Then the Impulse Moves to the Atrioventricular (AV) Node and Down the Bundle Branches Which Causes the
Ventricles to Contract
SA node
bull Prevent impulse generation in the SA node
bull Inhibit impulse conduction
AV node
Diseased Heart Tissue May
bull Pulse generator power source or battery
bull Leads or wiresbull Cathode (negative
electrode)bull Anode (positive
electrode)bull Body tissue
IPG
Lead
Anode
Cathode
Pacemaker Components Combine with Body Tissue to Form a Complete Circuit
bull Contains a battery that provides the energy for sending electrical impulses to the heart
bull Houses the circuitry that controls pacemaker operations
Circuitry
Battery
The Pulse Generator
bull Deliver electrical impulses from the pulse generator to the heart
bull Sense cardiac depolarization
Lead
Leads Are Insulated Wires That
bull Endocardial or transvenous leadsbull MyocardialEpicardial leads
Fixation Mechanismsbull Passive fixation
ndash The tines become lodged in the trabeculae(fibrous meshwork) of the heart
bull Active Fixation ndash The helix (or screw) extends into the endocardial
tissue
Types of Leads
Myocardial and Epicardial Leads
bull Leads applied directly to the heartndash Fixation mechanisms
includebull Epicardial stab-inbull Myocardial screw-inbull Suture-on
Cathodebull An electrode that is in contact
with the heart tissuebull Negatively charged when
electrical current is flowing
Anodebull An electrode that receives
the electrical impulse after depolarization of cardiac tissue
bull Positively charged when electrical current is flowing
CathodeAnode
Conduction Pathways
bull Body tissues and fluids are part of the conduction pathway between the anode and cathode
Tissue
Cathode
Anode
bull Begins in the pulse generator
bull Flows through the lead and the cathode (ndash)
bull Stimulates the heartbull Returns to the anode
(+)
During Pacing the ImpulseImpulse onset
Unipolar Pacingbull Current Flows through the tip
electrode (cathode)bull Stimulates the heartbull Returns through body fluid
and tissue to the IPG (anode)
Cathode
Anode
A Bipolar Pacingbull Flows through the tip electrode
located at the end of the lead wire
bull Stimulates the heartbull Returns to the ring electrode
above the lead tip
Anode
Cathode
Single-Chamber Systembull The pacing lead is implanted
in the atrium or ventricle depending on the chamber to be paced and sensed
Dual-Chamber Systemsbull Have Two Leadsbull One lead implanted in the
atrium bull One lead implanted in the
ventricle
METHODS OF PACING
Epicardialbull Used in patients that have undergone open heart surgerybull 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 chestand back of a patient and attached to anexternal pulse generator
METHODS OF PACING
Implanted pulse generatorbull A small device is surgically placed in a
subcutaneous pocket
Transvenousbull Via central line a lead is thread down to the RV
Transcutaneous Pacingbull Simple procedurebull ndash Pacing padsbull ndash Easy to applybull ndash Non invasivebull ndash Most monitor-defibrillators are also pacersbull ndash Can be one person procedurebull ndash Pads to chest wallbull ndash Attached to monitor-defibrillatorbull ndash Bridge until more permanent device can be
inserted
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Objectives
bull Indications for pacingbull NASPE BPEG nomenclaturebull Assessment reassessment of patient
Indications
bull Hemodynamically unstable bradycardiabull ndash Systolic blood pressure lt 80-90bull ndash Altered mental statusbull ndash AMI (chest pain angina)bull ndash CHF Pulmonary edemabull Failure of pharmacologic therapybull Risk of high degree AV blockbull Bradyasystolic cardiac arrestbull Overdrive pacing (SVT V tach)
Contraindications
bull Rhythm misinterpretationbull ndash Asystole mistaken as v-fibbull Severe hypothermiabull ndash May precipitate v-fib Correct temperature firstbull Relative Contraindicationbull ndash Bradyasystolic arrest lasting longer than 20bull minutes Chance of success is low
The Heart Has an Intrinsic Pacemaker
bull The heart generates electrical impulses thatbull travel along a specialized conduction pathwaybull This conduction process makes it possible forbull the heart to pump blood efficientlybull Remember the heartrsquos anatomy ampbull physiology
Ventricles
Sinoatrial (SA) Node
Atrioventricular (AV) Node
Atria
During Conduction an Impulse Begins in the Sinoatrial (SA) Node and Causes the Atria to
Contract
Atria
Ventricles
Bundle branches
AV node
SA node
Then the Impulse Moves to the Atrioventricular (AV) Node and Down the Bundle Branches Which Causes the
Ventricles to Contract
SA node
bull Prevent impulse generation in the SA node
bull Inhibit impulse conduction
AV node
Diseased Heart Tissue May
bull Pulse generator power source or battery
bull Leads or wiresbull Cathode (negative
electrode)bull Anode (positive
electrode)bull Body tissue
IPG
Lead
Anode
Cathode
Pacemaker Components Combine with Body Tissue to Form a Complete Circuit
bull Contains a battery that provides the energy for sending electrical impulses to the heart
bull Houses the circuitry that controls pacemaker operations
Circuitry
Battery
The Pulse Generator
bull Deliver electrical impulses from the pulse generator to the heart
bull Sense cardiac depolarization
Lead
Leads Are Insulated Wires That
bull Endocardial or transvenous leadsbull MyocardialEpicardial leads
Fixation Mechanismsbull Passive fixation
ndash The tines become lodged in the trabeculae(fibrous meshwork) of the heart
bull Active Fixation ndash The helix (or screw) extends into the endocardial
tissue
Types of Leads
Myocardial and Epicardial Leads
bull Leads applied directly to the heartndash Fixation mechanisms
includebull Epicardial stab-inbull Myocardial screw-inbull Suture-on
Cathodebull An electrode that is in contact
with the heart tissuebull Negatively charged when
electrical current is flowing
Anodebull An electrode that receives
the electrical impulse after depolarization of cardiac tissue
bull Positively charged when electrical current is flowing
CathodeAnode
Conduction Pathways
bull Body tissues and fluids are part of the conduction pathway between the anode and cathode
Tissue
Cathode
Anode
bull Begins in the pulse generator
bull Flows through the lead and the cathode (ndash)
bull Stimulates the heartbull Returns to the anode
(+)
During Pacing the ImpulseImpulse onset
Unipolar Pacingbull Current Flows through the tip
electrode (cathode)bull Stimulates the heartbull Returns through body fluid
and tissue to the IPG (anode)
Cathode
Anode
A Bipolar Pacingbull Flows through the tip electrode
located at the end of the lead wire
bull Stimulates the heartbull Returns to the ring electrode
above the lead tip
Anode
Cathode
Single-Chamber Systembull The pacing lead is implanted
in the atrium or ventricle depending on the chamber to be paced and sensed
Dual-Chamber Systemsbull Have Two Leadsbull One lead implanted in the
atrium bull One lead implanted in the
ventricle
METHODS OF PACING
Epicardialbull Used in patients that have undergone open heart surgerybull 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 chestand back of a patient and attached to anexternal pulse generator
METHODS OF PACING
Implanted pulse generatorbull A small device is surgically placed in a
subcutaneous pocket
Transvenousbull Via central line a lead is thread down to the RV
Transcutaneous Pacingbull Simple procedurebull ndash Pacing padsbull ndash Easy to applybull ndash Non invasivebull ndash Most monitor-defibrillators are also pacersbull ndash Can be one person procedurebull ndash Pads to chest wallbull ndash Attached to monitor-defibrillatorbull ndash Bridge until more permanent device can be
inserted
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Indications
bull Hemodynamically unstable bradycardiabull ndash Systolic blood pressure lt 80-90bull ndash Altered mental statusbull ndash AMI (chest pain angina)bull ndash CHF Pulmonary edemabull Failure of pharmacologic therapybull Risk of high degree AV blockbull Bradyasystolic cardiac arrestbull Overdrive pacing (SVT V tach)
Contraindications
bull Rhythm misinterpretationbull ndash Asystole mistaken as v-fibbull Severe hypothermiabull ndash May precipitate v-fib Correct temperature firstbull Relative Contraindicationbull ndash Bradyasystolic arrest lasting longer than 20bull minutes Chance of success is low
The Heart Has an Intrinsic Pacemaker
bull The heart generates electrical impulses thatbull travel along a specialized conduction pathwaybull This conduction process makes it possible forbull the heart to pump blood efficientlybull Remember the heartrsquos anatomy ampbull physiology
Ventricles
Sinoatrial (SA) Node
Atrioventricular (AV) Node
Atria
During Conduction an Impulse Begins in the Sinoatrial (SA) Node and Causes the Atria to
Contract
Atria
Ventricles
Bundle branches
AV node
SA node
Then the Impulse Moves to the Atrioventricular (AV) Node and Down the Bundle Branches Which Causes the
Ventricles to Contract
SA node
bull Prevent impulse generation in the SA node
bull Inhibit impulse conduction
AV node
Diseased Heart Tissue May
bull Pulse generator power source or battery
bull Leads or wiresbull Cathode (negative
electrode)bull Anode (positive
electrode)bull Body tissue
IPG
Lead
Anode
Cathode
Pacemaker Components Combine with Body Tissue to Form a Complete Circuit
bull Contains a battery that provides the energy for sending electrical impulses to the heart
bull Houses the circuitry that controls pacemaker operations
Circuitry
Battery
The Pulse Generator
bull Deliver electrical impulses from the pulse generator to the heart
bull Sense cardiac depolarization
Lead
Leads Are Insulated Wires That
bull Endocardial or transvenous leadsbull MyocardialEpicardial leads
Fixation Mechanismsbull Passive fixation
ndash The tines become lodged in the trabeculae(fibrous meshwork) of the heart
bull Active Fixation ndash The helix (or screw) extends into the endocardial
tissue
Types of Leads
Myocardial and Epicardial Leads
bull Leads applied directly to the heartndash Fixation mechanisms
includebull Epicardial stab-inbull Myocardial screw-inbull Suture-on
Cathodebull An electrode that is in contact
with the heart tissuebull Negatively charged when
electrical current is flowing
Anodebull An electrode that receives
the electrical impulse after depolarization of cardiac tissue
bull Positively charged when electrical current is flowing
CathodeAnode
Conduction Pathways
bull Body tissues and fluids are part of the conduction pathway between the anode and cathode
Tissue
Cathode
Anode
bull Begins in the pulse generator
bull Flows through the lead and the cathode (ndash)
bull Stimulates the heartbull Returns to the anode
(+)
During Pacing the ImpulseImpulse onset
Unipolar Pacingbull Current Flows through the tip
electrode (cathode)bull Stimulates the heartbull Returns through body fluid
and tissue to the IPG (anode)
Cathode
Anode
A Bipolar Pacingbull Flows through the tip electrode
located at the end of the lead wire
bull Stimulates the heartbull Returns to the ring electrode
above the lead tip
Anode
Cathode
Single-Chamber Systembull The pacing lead is implanted
in the atrium or ventricle depending on the chamber to be paced and sensed
Dual-Chamber Systemsbull Have Two Leadsbull One lead implanted in the
atrium bull One lead implanted in the
ventricle
METHODS OF PACING
Epicardialbull Used in patients that have undergone open heart surgerybull 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 chestand back of a patient and attached to anexternal pulse generator
METHODS OF PACING
Implanted pulse generatorbull A small device is surgically placed in a
subcutaneous pocket
Transvenousbull Via central line a lead is thread down to the RV
Transcutaneous Pacingbull Simple procedurebull ndash Pacing padsbull ndash Easy to applybull ndash Non invasivebull ndash Most monitor-defibrillators are also pacersbull ndash Can be one person procedurebull ndash Pads to chest wallbull ndash Attached to monitor-defibrillatorbull ndash Bridge until more permanent device can be
inserted
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Contraindications
bull Rhythm misinterpretationbull ndash Asystole mistaken as v-fibbull Severe hypothermiabull ndash May precipitate v-fib Correct temperature firstbull Relative Contraindicationbull ndash Bradyasystolic arrest lasting longer than 20bull minutes Chance of success is low
The Heart Has an Intrinsic Pacemaker
bull The heart generates electrical impulses thatbull travel along a specialized conduction pathwaybull This conduction process makes it possible forbull the heart to pump blood efficientlybull Remember the heartrsquos anatomy ampbull physiology
Ventricles
Sinoatrial (SA) Node
Atrioventricular (AV) Node
Atria
During Conduction an Impulse Begins in the Sinoatrial (SA) Node and Causes the Atria to
Contract
Atria
Ventricles
Bundle branches
AV node
SA node
Then the Impulse Moves to the Atrioventricular (AV) Node and Down the Bundle Branches Which Causes the
Ventricles to Contract
SA node
bull Prevent impulse generation in the SA node
bull Inhibit impulse conduction
AV node
Diseased Heart Tissue May
bull Pulse generator power source or battery
bull Leads or wiresbull Cathode (negative
electrode)bull Anode (positive
electrode)bull Body tissue
IPG
Lead
Anode
Cathode
Pacemaker Components Combine with Body Tissue to Form a Complete Circuit
bull Contains a battery that provides the energy for sending electrical impulses to the heart
bull Houses the circuitry that controls pacemaker operations
Circuitry
Battery
The Pulse Generator
bull Deliver electrical impulses from the pulse generator to the heart
bull Sense cardiac depolarization
Lead
Leads Are Insulated Wires That
bull Endocardial or transvenous leadsbull MyocardialEpicardial leads
Fixation Mechanismsbull Passive fixation
ndash The tines become lodged in the trabeculae(fibrous meshwork) of the heart
bull Active Fixation ndash The helix (or screw) extends into the endocardial
tissue
Types of Leads
Myocardial and Epicardial Leads
bull Leads applied directly to the heartndash Fixation mechanisms
includebull Epicardial stab-inbull Myocardial screw-inbull Suture-on
Cathodebull An electrode that is in contact
with the heart tissuebull Negatively charged when
electrical current is flowing
Anodebull An electrode that receives
the electrical impulse after depolarization of cardiac tissue
bull Positively charged when electrical current is flowing
CathodeAnode
Conduction Pathways
bull Body tissues and fluids are part of the conduction pathway between the anode and cathode
Tissue
Cathode
Anode
bull Begins in the pulse generator
bull Flows through the lead and the cathode (ndash)
bull Stimulates the heartbull Returns to the anode
(+)
During Pacing the ImpulseImpulse onset
Unipolar Pacingbull Current Flows through the tip
electrode (cathode)bull Stimulates the heartbull Returns through body fluid
and tissue to the IPG (anode)
Cathode
Anode
A Bipolar Pacingbull Flows through the tip electrode
located at the end of the lead wire
bull Stimulates the heartbull Returns to the ring electrode
above the lead tip
Anode
Cathode
Single-Chamber Systembull The pacing lead is implanted
in the atrium or ventricle depending on the chamber to be paced and sensed
Dual-Chamber Systemsbull Have Two Leadsbull One lead implanted in the
atrium bull One lead implanted in the
ventricle
METHODS OF PACING
Epicardialbull Used in patients that have undergone open heart surgerybull 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 chestand back of a patient and attached to anexternal pulse generator
METHODS OF PACING
Implanted pulse generatorbull A small device is surgically placed in a
subcutaneous pocket
Transvenousbull Via central line a lead is thread down to the RV
Transcutaneous Pacingbull Simple procedurebull ndash Pacing padsbull ndash Easy to applybull ndash Non invasivebull ndash Most monitor-defibrillators are also pacersbull ndash Can be one person procedurebull ndash Pads to chest wallbull ndash Attached to monitor-defibrillatorbull ndash Bridge until more permanent device can be
inserted
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
The Heart Has an Intrinsic Pacemaker
bull The heart generates electrical impulses thatbull travel along a specialized conduction pathwaybull This conduction process makes it possible forbull the heart to pump blood efficientlybull Remember the heartrsquos anatomy ampbull physiology
Ventricles
Sinoatrial (SA) Node
Atrioventricular (AV) Node
Atria
During Conduction an Impulse Begins in the Sinoatrial (SA) Node and Causes the Atria to
Contract
Atria
Ventricles
Bundle branches
AV node
SA node
Then the Impulse Moves to the Atrioventricular (AV) Node and Down the Bundle Branches Which Causes the
Ventricles to Contract
SA node
bull Prevent impulse generation in the SA node
bull Inhibit impulse conduction
AV node
Diseased Heart Tissue May
bull Pulse generator power source or battery
bull Leads or wiresbull Cathode (negative
electrode)bull Anode (positive
electrode)bull Body tissue
IPG
Lead
Anode
Cathode
Pacemaker Components Combine with Body Tissue to Form a Complete Circuit
bull Contains a battery that provides the energy for sending electrical impulses to the heart
bull Houses the circuitry that controls pacemaker operations
Circuitry
Battery
The Pulse Generator
bull Deliver electrical impulses from the pulse generator to the heart
bull Sense cardiac depolarization
Lead
Leads Are Insulated Wires That
bull Endocardial or transvenous leadsbull MyocardialEpicardial leads
Fixation Mechanismsbull Passive fixation
ndash The tines become lodged in the trabeculae(fibrous meshwork) of the heart
bull Active Fixation ndash The helix (or screw) extends into the endocardial
tissue
Types of Leads
Myocardial and Epicardial Leads
bull Leads applied directly to the heartndash Fixation mechanisms
includebull Epicardial stab-inbull Myocardial screw-inbull Suture-on
Cathodebull An electrode that is in contact
with the heart tissuebull Negatively charged when
electrical current is flowing
Anodebull An electrode that receives
the electrical impulse after depolarization of cardiac tissue
bull Positively charged when electrical current is flowing
CathodeAnode
Conduction Pathways
bull Body tissues and fluids are part of the conduction pathway between the anode and cathode
Tissue
Cathode
Anode
bull Begins in the pulse generator
bull Flows through the lead and the cathode (ndash)
bull Stimulates the heartbull Returns to the anode
(+)
During Pacing the ImpulseImpulse onset
Unipolar Pacingbull Current Flows through the tip
electrode (cathode)bull Stimulates the heartbull Returns through body fluid
and tissue to the IPG (anode)
Cathode
Anode
A Bipolar Pacingbull Flows through the tip electrode
located at the end of the lead wire
bull Stimulates the heartbull Returns to the ring electrode
above the lead tip
Anode
Cathode
Single-Chamber Systembull The pacing lead is implanted
in the atrium or ventricle depending on the chamber to be paced and sensed
Dual-Chamber Systemsbull Have Two Leadsbull One lead implanted in the
atrium bull One lead implanted in the
ventricle
METHODS OF PACING
Epicardialbull Used in patients that have undergone open heart surgerybull 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 chestand back of a patient and attached to anexternal pulse generator
METHODS OF PACING
Implanted pulse generatorbull A small device is surgically placed in a
subcutaneous pocket
Transvenousbull Via central line a lead is thread down to the RV
Transcutaneous Pacingbull Simple procedurebull ndash Pacing padsbull ndash Easy to applybull ndash Non invasivebull ndash Most monitor-defibrillators are also pacersbull ndash Can be one person procedurebull ndash Pads to chest wallbull ndash Attached to monitor-defibrillatorbull ndash Bridge until more permanent device can be
inserted
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Ventricles
Sinoatrial (SA) Node
Atrioventricular (AV) Node
Atria
During Conduction an Impulse Begins in the Sinoatrial (SA) Node and Causes the Atria to
Contract
Atria
Ventricles
Bundle branches
AV node
SA node
Then the Impulse Moves to the Atrioventricular (AV) Node and Down the Bundle Branches Which Causes the
Ventricles to Contract
SA node
bull Prevent impulse generation in the SA node
bull Inhibit impulse conduction
AV node
Diseased Heart Tissue May
bull Pulse generator power source or battery
bull Leads or wiresbull Cathode (negative
electrode)bull Anode (positive
electrode)bull Body tissue
IPG
Lead
Anode
Cathode
Pacemaker Components Combine with Body Tissue to Form a Complete Circuit
bull Contains a battery that provides the energy for sending electrical impulses to the heart
bull Houses the circuitry that controls pacemaker operations
Circuitry
Battery
The Pulse Generator
bull Deliver electrical impulses from the pulse generator to the heart
bull Sense cardiac depolarization
Lead
Leads Are Insulated Wires That
bull Endocardial or transvenous leadsbull MyocardialEpicardial leads
Fixation Mechanismsbull Passive fixation
ndash The tines become lodged in the trabeculae(fibrous meshwork) of the heart
bull Active Fixation ndash The helix (or screw) extends into the endocardial
tissue
Types of Leads
Myocardial and Epicardial Leads
bull Leads applied directly to the heartndash Fixation mechanisms
includebull Epicardial stab-inbull Myocardial screw-inbull Suture-on
Cathodebull An electrode that is in contact
with the heart tissuebull Negatively charged when
electrical current is flowing
Anodebull An electrode that receives
the electrical impulse after depolarization of cardiac tissue
bull Positively charged when electrical current is flowing
CathodeAnode
Conduction Pathways
bull Body tissues and fluids are part of the conduction pathway between the anode and cathode
Tissue
Cathode
Anode
bull Begins in the pulse generator
bull Flows through the lead and the cathode (ndash)
bull Stimulates the heartbull Returns to the anode
(+)
During Pacing the ImpulseImpulse onset
Unipolar Pacingbull Current Flows through the tip
electrode (cathode)bull Stimulates the heartbull Returns through body fluid
and tissue to the IPG (anode)
Cathode
Anode
A Bipolar Pacingbull Flows through the tip electrode
located at the end of the lead wire
bull Stimulates the heartbull Returns to the ring electrode
above the lead tip
Anode
Cathode
Single-Chamber Systembull The pacing lead is implanted
in the atrium or ventricle depending on the chamber to be paced and sensed
Dual-Chamber Systemsbull Have Two Leadsbull One lead implanted in the
atrium bull One lead implanted in the
ventricle
METHODS OF PACING
Epicardialbull Used in patients that have undergone open heart surgerybull 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 chestand back of a patient and attached to anexternal pulse generator
METHODS OF PACING
Implanted pulse generatorbull A small device is surgically placed in a
subcutaneous pocket
Transvenousbull Via central line a lead is thread down to the RV
Transcutaneous Pacingbull Simple procedurebull ndash Pacing padsbull ndash Easy to applybull ndash Non invasivebull ndash Most monitor-defibrillators are also pacersbull ndash Can be one person procedurebull ndash Pads to chest wallbull ndash Attached to monitor-defibrillatorbull ndash Bridge until more permanent device can be
inserted
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Atria
Ventricles
Bundle branches
AV node
SA node
Then the Impulse Moves to the Atrioventricular (AV) Node and Down the Bundle Branches Which Causes the
Ventricles to Contract
SA node
bull Prevent impulse generation in the SA node
bull Inhibit impulse conduction
AV node
Diseased Heart Tissue May
bull Pulse generator power source or battery
bull Leads or wiresbull Cathode (negative
electrode)bull Anode (positive
electrode)bull Body tissue
IPG
Lead
Anode
Cathode
Pacemaker Components Combine with Body Tissue to Form a Complete Circuit
bull Contains a battery that provides the energy for sending electrical impulses to the heart
bull Houses the circuitry that controls pacemaker operations
Circuitry
Battery
The Pulse Generator
bull Deliver electrical impulses from the pulse generator to the heart
bull Sense cardiac depolarization
Lead
Leads Are Insulated Wires That
bull Endocardial or transvenous leadsbull MyocardialEpicardial leads
Fixation Mechanismsbull Passive fixation
ndash The tines become lodged in the trabeculae(fibrous meshwork) of the heart
bull Active Fixation ndash The helix (or screw) extends into the endocardial
tissue
Types of Leads
Myocardial and Epicardial Leads
bull Leads applied directly to the heartndash Fixation mechanisms
includebull Epicardial stab-inbull Myocardial screw-inbull Suture-on
Cathodebull An electrode that is in contact
with the heart tissuebull Negatively charged when
electrical current is flowing
Anodebull An electrode that receives
the electrical impulse after depolarization of cardiac tissue
bull Positively charged when electrical current is flowing
CathodeAnode
Conduction Pathways
bull Body tissues and fluids are part of the conduction pathway between the anode and cathode
Tissue
Cathode
Anode
bull Begins in the pulse generator
bull Flows through the lead and the cathode (ndash)
bull Stimulates the heartbull Returns to the anode
(+)
During Pacing the ImpulseImpulse onset
Unipolar Pacingbull Current Flows through the tip
electrode (cathode)bull Stimulates the heartbull Returns through body fluid
and tissue to the IPG (anode)
Cathode
Anode
A Bipolar Pacingbull Flows through the tip electrode
located at the end of the lead wire
bull Stimulates the heartbull Returns to the ring electrode
above the lead tip
Anode
Cathode
Single-Chamber Systembull The pacing lead is implanted
in the atrium or ventricle depending on the chamber to be paced and sensed
Dual-Chamber Systemsbull Have Two Leadsbull One lead implanted in the
atrium bull One lead implanted in the
ventricle
METHODS OF PACING
Epicardialbull Used in patients that have undergone open heart surgerybull 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 chestand back of a patient and attached to anexternal pulse generator
METHODS OF PACING
Implanted pulse generatorbull A small device is surgically placed in a
subcutaneous pocket
Transvenousbull Via central line a lead is thread down to the RV
Transcutaneous Pacingbull Simple procedurebull ndash Pacing padsbull ndash Easy to applybull ndash Non invasivebull ndash Most monitor-defibrillators are also pacersbull ndash Can be one person procedurebull ndash Pads to chest wallbull ndash Attached to monitor-defibrillatorbull ndash Bridge until more permanent device can be
inserted
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
SA node
bull Prevent impulse generation in the SA node
bull Inhibit impulse conduction
AV node
Diseased Heart Tissue May
bull Pulse generator power source or battery
bull Leads or wiresbull Cathode (negative
electrode)bull Anode (positive
electrode)bull Body tissue
IPG
Lead
Anode
Cathode
Pacemaker Components Combine with Body Tissue to Form a Complete Circuit
bull Contains a battery that provides the energy for sending electrical impulses to the heart
bull Houses the circuitry that controls pacemaker operations
Circuitry
Battery
The Pulse Generator
bull Deliver electrical impulses from the pulse generator to the heart
bull Sense cardiac depolarization
Lead
Leads Are Insulated Wires That
bull Endocardial or transvenous leadsbull MyocardialEpicardial leads
Fixation Mechanismsbull Passive fixation
ndash The tines become lodged in the trabeculae(fibrous meshwork) of the heart
bull Active Fixation ndash The helix (or screw) extends into the endocardial
tissue
Types of Leads
Myocardial and Epicardial Leads
bull Leads applied directly to the heartndash Fixation mechanisms
includebull Epicardial stab-inbull Myocardial screw-inbull Suture-on
Cathodebull An electrode that is in contact
with the heart tissuebull Negatively charged when
electrical current is flowing
Anodebull An electrode that receives
the electrical impulse after depolarization of cardiac tissue
bull Positively charged when electrical current is flowing
CathodeAnode
Conduction Pathways
bull Body tissues and fluids are part of the conduction pathway between the anode and cathode
Tissue
Cathode
Anode
bull Begins in the pulse generator
bull Flows through the lead and the cathode (ndash)
bull Stimulates the heartbull Returns to the anode
(+)
During Pacing the ImpulseImpulse onset
Unipolar Pacingbull Current Flows through the tip
electrode (cathode)bull Stimulates the heartbull Returns through body fluid
and tissue to the IPG (anode)
Cathode
Anode
A Bipolar Pacingbull Flows through the tip electrode
located at the end of the lead wire
bull Stimulates the heartbull Returns to the ring electrode
above the lead tip
Anode
Cathode
Single-Chamber Systembull The pacing lead is implanted
in the atrium or ventricle depending on the chamber to be paced and sensed
Dual-Chamber Systemsbull Have Two Leadsbull One lead implanted in the
atrium bull One lead implanted in the
ventricle
METHODS OF PACING
Epicardialbull Used in patients that have undergone open heart surgerybull 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 chestand back of a patient and attached to anexternal pulse generator
METHODS OF PACING
Implanted pulse generatorbull A small device is surgically placed in a
subcutaneous pocket
Transvenousbull Via central line a lead is thread down to the RV
Transcutaneous Pacingbull Simple procedurebull ndash Pacing padsbull ndash Easy to applybull ndash Non invasivebull ndash Most monitor-defibrillators are also pacersbull ndash Can be one person procedurebull ndash Pads to chest wallbull ndash Attached to monitor-defibrillatorbull ndash Bridge until more permanent device can be
inserted
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
bull Pulse generator power source or battery
bull Leads or wiresbull Cathode (negative
electrode)bull Anode (positive
electrode)bull Body tissue
IPG
Lead
Anode
Cathode
Pacemaker Components Combine with Body Tissue to Form a Complete Circuit
bull Contains a battery that provides the energy for sending electrical impulses to the heart
bull Houses the circuitry that controls pacemaker operations
Circuitry
Battery
The Pulse Generator
bull Deliver electrical impulses from the pulse generator to the heart
bull Sense cardiac depolarization
Lead
Leads Are Insulated Wires That
bull Endocardial or transvenous leadsbull MyocardialEpicardial leads
Fixation Mechanismsbull Passive fixation
ndash The tines become lodged in the trabeculae(fibrous meshwork) of the heart
bull Active Fixation ndash The helix (or screw) extends into the endocardial
tissue
Types of Leads
Myocardial and Epicardial Leads
bull Leads applied directly to the heartndash Fixation mechanisms
includebull Epicardial stab-inbull Myocardial screw-inbull Suture-on
Cathodebull An electrode that is in contact
with the heart tissuebull Negatively charged when
electrical current is flowing
Anodebull An electrode that receives
the electrical impulse after depolarization of cardiac tissue
bull Positively charged when electrical current is flowing
CathodeAnode
Conduction Pathways
bull Body tissues and fluids are part of the conduction pathway between the anode and cathode
Tissue
Cathode
Anode
bull Begins in the pulse generator
bull Flows through the lead and the cathode (ndash)
bull Stimulates the heartbull Returns to the anode
(+)
During Pacing the ImpulseImpulse onset
Unipolar Pacingbull Current Flows through the tip
electrode (cathode)bull Stimulates the heartbull Returns through body fluid
and tissue to the IPG (anode)
Cathode
Anode
A Bipolar Pacingbull Flows through the tip electrode
located at the end of the lead wire
bull Stimulates the heartbull Returns to the ring electrode
above the lead tip
Anode
Cathode
Single-Chamber Systembull The pacing lead is implanted
in the atrium or ventricle depending on the chamber to be paced and sensed
Dual-Chamber Systemsbull Have Two Leadsbull One lead implanted in the
atrium bull One lead implanted in the
ventricle
METHODS OF PACING
Epicardialbull Used in patients that have undergone open heart surgerybull 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 chestand back of a patient and attached to anexternal pulse generator
METHODS OF PACING
Implanted pulse generatorbull A small device is surgically placed in a
subcutaneous pocket
Transvenousbull Via central line a lead is thread down to the RV
Transcutaneous Pacingbull Simple procedurebull ndash Pacing padsbull ndash Easy to applybull ndash Non invasivebull ndash Most monitor-defibrillators are also pacersbull ndash Can be one person procedurebull ndash Pads to chest wallbull ndash Attached to monitor-defibrillatorbull ndash Bridge until more permanent device can be
inserted
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
bull Contains a battery that provides the energy for sending electrical impulses to the heart
bull Houses the circuitry that controls pacemaker operations
Circuitry
Battery
The Pulse Generator
bull Deliver electrical impulses from the pulse generator to the heart
bull Sense cardiac depolarization
Lead
Leads Are Insulated Wires That
bull Endocardial or transvenous leadsbull MyocardialEpicardial leads
Fixation Mechanismsbull Passive fixation
ndash The tines become lodged in the trabeculae(fibrous meshwork) of the heart
bull Active Fixation ndash The helix (or screw) extends into the endocardial
tissue
Types of Leads
Myocardial and Epicardial Leads
bull Leads applied directly to the heartndash Fixation mechanisms
includebull Epicardial stab-inbull Myocardial screw-inbull Suture-on
Cathodebull An electrode that is in contact
with the heart tissuebull Negatively charged when
electrical current is flowing
Anodebull An electrode that receives
the electrical impulse after depolarization of cardiac tissue
bull Positively charged when electrical current is flowing
CathodeAnode
Conduction Pathways
bull Body tissues and fluids are part of the conduction pathway between the anode and cathode
Tissue
Cathode
Anode
bull Begins in the pulse generator
bull Flows through the lead and the cathode (ndash)
bull Stimulates the heartbull Returns to the anode
(+)
During Pacing the ImpulseImpulse onset
Unipolar Pacingbull Current Flows through the tip
electrode (cathode)bull Stimulates the heartbull Returns through body fluid
and tissue to the IPG (anode)
Cathode
Anode
A Bipolar Pacingbull Flows through the tip electrode
located at the end of the lead wire
bull Stimulates the heartbull Returns to the ring electrode
above the lead tip
Anode
Cathode
Single-Chamber Systembull The pacing lead is implanted
in the atrium or ventricle depending on the chamber to be paced and sensed
Dual-Chamber Systemsbull Have Two Leadsbull One lead implanted in the
atrium bull One lead implanted in the
ventricle
METHODS OF PACING
Epicardialbull Used in patients that have undergone open heart surgerybull 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 chestand back of a patient and attached to anexternal pulse generator
METHODS OF PACING
Implanted pulse generatorbull A small device is surgically placed in a
subcutaneous pocket
Transvenousbull Via central line a lead is thread down to the RV
Transcutaneous Pacingbull Simple procedurebull ndash Pacing padsbull ndash Easy to applybull ndash Non invasivebull ndash Most monitor-defibrillators are also pacersbull ndash Can be one person procedurebull ndash Pads to chest wallbull ndash Attached to monitor-defibrillatorbull ndash Bridge until more permanent device can be
inserted
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
bull Deliver electrical impulses from the pulse generator to the heart
bull Sense cardiac depolarization
Lead
Leads Are Insulated Wires That
bull Endocardial or transvenous leadsbull MyocardialEpicardial leads
Fixation Mechanismsbull Passive fixation
ndash The tines become lodged in the trabeculae(fibrous meshwork) of the heart
bull Active Fixation ndash The helix (or screw) extends into the endocardial
tissue
Types of Leads
Myocardial and Epicardial Leads
bull Leads applied directly to the heartndash Fixation mechanisms
includebull Epicardial stab-inbull Myocardial screw-inbull Suture-on
Cathodebull An electrode that is in contact
with the heart tissuebull Negatively charged when
electrical current is flowing
Anodebull An electrode that receives
the electrical impulse after depolarization of cardiac tissue
bull Positively charged when electrical current is flowing
CathodeAnode
Conduction Pathways
bull Body tissues and fluids are part of the conduction pathway between the anode and cathode
Tissue
Cathode
Anode
bull Begins in the pulse generator
bull Flows through the lead and the cathode (ndash)
bull Stimulates the heartbull Returns to the anode
(+)
During Pacing the ImpulseImpulse onset
Unipolar Pacingbull Current Flows through the tip
electrode (cathode)bull Stimulates the heartbull Returns through body fluid
and tissue to the IPG (anode)
Cathode
Anode
A Bipolar Pacingbull Flows through the tip electrode
located at the end of the lead wire
bull Stimulates the heartbull Returns to the ring electrode
above the lead tip
Anode
Cathode
Single-Chamber Systembull The pacing lead is implanted
in the atrium or ventricle depending on the chamber to be paced and sensed
Dual-Chamber Systemsbull Have Two Leadsbull One lead implanted in the
atrium bull One lead implanted in the
ventricle
METHODS OF PACING
Epicardialbull Used in patients that have undergone open heart surgerybull 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 chestand back of a patient and attached to anexternal pulse generator
METHODS OF PACING
Implanted pulse generatorbull A small device is surgically placed in a
subcutaneous pocket
Transvenousbull Via central line a lead is thread down to the RV
Transcutaneous Pacingbull Simple procedurebull ndash Pacing padsbull ndash Easy to applybull ndash Non invasivebull ndash Most monitor-defibrillators are also pacersbull ndash Can be one person procedurebull ndash Pads to chest wallbull ndash Attached to monitor-defibrillatorbull ndash Bridge until more permanent device can be
inserted
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
bull Endocardial or transvenous leadsbull MyocardialEpicardial leads
Fixation Mechanismsbull Passive fixation
ndash The tines become lodged in the trabeculae(fibrous meshwork) of the heart
bull Active Fixation ndash The helix (or screw) extends into the endocardial
tissue
Types of Leads
Myocardial and Epicardial Leads
bull Leads applied directly to the heartndash Fixation mechanisms
includebull Epicardial stab-inbull Myocardial screw-inbull Suture-on
Cathodebull An electrode that is in contact
with the heart tissuebull Negatively charged when
electrical current is flowing
Anodebull An electrode that receives
the electrical impulse after depolarization of cardiac tissue
bull Positively charged when electrical current is flowing
CathodeAnode
Conduction Pathways
bull Body tissues and fluids are part of the conduction pathway between the anode and cathode
Tissue
Cathode
Anode
bull Begins in the pulse generator
bull Flows through the lead and the cathode (ndash)
bull Stimulates the heartbull Returns to the anode
(+)
During Pacing the ImpulseImpulse onset
Unipolar Pacingbull Current Flows through the tip
electrode (cathode)bull Stimulates the heartbull Returns through body fluid
and tissue to the IPG (anode)
Cathode
Anode
A Bipolar Pacingbull Flows through the tip electrode
located at the end of the lead wire
bull Stimulates the heartbull Returns to the ring electrode
above the lead tip
Anode
Cathode
Single-Chamber Systembull The pacing lead is implanted
in the atrium or ventricle depending on the chamber to be paced and sensed
Dual-Chamber Systemsbull Have Two Leadsbull One lead implanted in the
atrium bull One lead implanted in the
ventricle
METHODS OF PACING
Epicardialbull Used in patients that have undergone open heart surgerybull 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 chestand back of a patient and attached to anexternal pulse generator
METHODS OF PACING
Implanted pulse generatorbull A small device is surgically placed in a
subcutaneous pocket
Transvenousbull Via central line a lead is thread down to the RV
Transcutaneous Pacingbull Simple procedurebull ndash Pacing padsbull ndash Easy to applybull ndash Non invasivebull ndash Most monitor-defibrillators are also pacersbull ndash Can be one person procedurebull ndash Pads to chest wallbull ndash Attached to monitor-defibrillatorbull ndash Bridge until more permanent device can be
inserted
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Myocardial and Epicardial Leads
bull Leads applied directly to the heartndash Fixation mechanisms
includebull Epicardial stab-inbull Myocardial screw-inbull Suture-on
Cathodebull An electrode that is in contact
with the heart tissuebull Negatively charged when
electrical current is flowing
Anodebull An electrode that receives
the electrical impulse after depolarization of cardiac tissue
bull Positively charged when electrical current is flowing
CathodeAnode
Conduction Pathways
bull Body tissues and fluids are part of the conduction pathway between the anode and cathode
Tissue
Cathode
Anode
bull Begins in the pulse generator
bull Flows through the lead and the cathode (ndash)
bull Stimulates the heartbull Returns to the anode
(+)
During Pacing the ImpulseImpulse onset
Unipolar Pacingbull Current Flows through the tip
electrode (cathode)bull Stimulates the heartbull Returns through body fluid
and tissue to the IPG (anode)
Cathode
Anode
A Bipolar Pacingbull Flows through the tip electrode
located at the end of the lead wire
bull Stimulates the heartbull Returns to the ring electrode
above the lead tip
Anode
Cathode
Single-Chamber Systembull The pacing lead is implanted
in the atrium or ventricle depending on the chamber to be paced and sensed
Dual-Chamber Systemsbull Have Two Leadsbull One lead implanted in the
atrium bull One lead implanted in the
ventricle
METHODS OF PACING
Epicardialbull Used in patients that have undergone open heart surgerybull 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 chestand back of a patient and attached to anexternal pulse generator
METHODS OF PACING
Implanted pulse generatorbull A small device is surgically placed in a
subcutaneous pocket
Transvenousbull Via central line a lead is thread down to the RV
Transcutaneous Pacingbull Simple procedurebull ndash Pacing padsbull ndash Easy to applybull ndash Non invasivebull ndash Most monitor-defibrillators are also pacersbull ndash Can be one person procedurebull ndash Pads to chest wallbull ndash Attached to monitor-defibrillatorbull ndash Bridge until more permanent device can be
inserted
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Cathodebull An electrode that is in contact
with the heart tissuebull Negatively charged when
electrical current is flowing
Anodebull An electrode that receives
the electrical impulse after depolarization of cardiac tissue
bull Positively charged when electrical current is flowing
CathodeAnode
Conduction Pathways
bull Body tissues and fluids are part of the conduction pathway between the anode and cathode
Tissue
Cathode
Anode
bull Begins in the pulse generator
bull Flows through the lead and the cathode (ndash)
bull Stimulates the heartbull Returns to the anode
(+)
During Pacing the ImpulseImpulse onset
Unipolar Pacingbull Current Flows through the tip
electrode (cathode)bull Stimulates the heartbull Returns through body fluid
and tissue to the IPG (anode)
Cathode
Anode
A Bipolar Pacingbull Flows through the tip electrode
located at the end of the lead wire
bull Stimulates the heartbull Returns to the ring electrode
above the lead tip
Anode
Cathode
Single-Chamber Systembull The pacing lead is implanted
in the atrium or ventricle depending on the chamber to be paced and sensed
Dual-Chamber Systemsbull Have Two Leadsbull One lead implanted in the
atrium bull One lead implanted in the
ventricle
METHODS OF PACING
Epicardialbull Used in patients that have undergone open heart surgerybull 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 chestand back of a patient and attached to anexternal pulse generator
METHODS OF PACING
Implanted pulse generatorbull A small device is surgically placed in a
subcutaneous pocket
Transvenousbull Via central line a lead is thread down to the RV
Transcutaneous Pacingbull Simple procedurebull ndash Pacing padsbull ndash Easy to applybull ndash Non invasivebull ndash Most monitor-defibrillators are also pacersbull ndash Can be one person procedurebull ndash Pads to chest wallbull ndash Attached to monitor-defibrillatorbull ndash Bridge until more permanent device can be
inserted
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Conduction Pathways
bull Body tissues and fluids are part of the conduction pathway between the anode and cathode
Tissue
Cathode
Anode
bull Begins in the pulse generator
bull Flows through the lead and the cathode (ndash)
bull Stimulates the heartbull Returns to the anode
(+)
During Pacing the ImpulseImpulse onset
Unipolar Pacingbull Current Flows through the tip
electrode (cathode)bull Stimulates the heartbull Returns through body fluid
and tissue to the IPG (anode)
Cathode
Anode
A Bipolar Pacingbull Flows through the tip electrode
located at the end of the lead wire
bull Stimulates the heartbull Returns to the ring electrode
above the lead tip
Anode
Cathode
Single-Chamber Systembull The pacing lead is implanted
in the atrium or ventricle depending on the chamber to be paced and sensed
Dual-Chamber Systemsbull Have Two Leadsbull One lead implanted in the
atrium bull One lead implanted in the
ventricle
METHODS OF PACING
Epicardialbull Used in patients that have undergone open heart surgerybull 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 chestand back of a patient and attached to anexternal pulse generator
METHODS OF PACING
Implanted pulse generatorbull A small device is surgically placed in a
subcutaneous pocket
Transvenousbull Via central line a lead is thread down to the RV
Transcutaneous Pacingbull Simple procedurebull ndash Pacing padsbull ndash Easy to applybull ndash Non invasivebull ndash Most monitor-defibrillators are also pacersbull ndash Can be one person procedurebull ndash Pads to chest wallbull ndash Attached to monitor-defibrillatorbull ndash Bridge until more permanent device can be
inserted
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
bull Begins in the pulse generator
bull Flows through the lead and the cathode (ndash)
bull Stimulates the heartbull Returns to the anode
(+)
During Pacing the ImpulseImpulse onset
Unipolar Pacingbull Current Flows through the tip
electrode (cathode)bull Stimulates the heartbull Returns through body fluid
and tissue to the IPG (anode)
Cathode
Anode
A Bipolar Pacingbull Flows through the tip electrode
located at the end of the lead wire
bull Stimulates the heartbull Returns to the ring electrode
above the lead tip
Anode
Cathode
Single-Chamber Systembull The pacing lead is implanted
in the atrium or ventricle depending on the chamber to be paced and sensed
Dual-Chamber Systemsbull Have Two Leadsbull One lead implanted in the
atrium bull One lead implanted in the
ventricle
METHODS OF PACING
Epicardialbull Used in patients that have undergone open heart surgerybull 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 chestand back of a patient and attached to anexternal pulse generator
METHODS OF PACING
Implanted pulse generatorbull A small device is surgically placed in a
subcutaneous pocket
Transvenousbull Via central line a lead is thread down to the RV
Transcutaneous Pacingbull Simple procedurebull ndash Pacing padsbull ndash Easy to applybull ndash Non invasivebull ndash Most monitor-defibrillators are also pacersbull ndash Can be one person procedurebull ndash Pads to chest wallbull ndash Attached to monitor-defibrillatorbull ndash Bridge until more permanent device can be
inserted
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Unipolar Pacingbull Current Flows through the tip
electrode (cathode)bull Stimulates the heartbull Returns through body fluid
and tissue to the IPG (anode)
Cathode
Anode
A Bipolar Pacingbull Flows through the tip electrode
located at the end of the lead wire
bull Stimulates the heartbull Returns to the ring electrode
above the lead tip
Anode
Cathode
Single-Chamber Systembull The pacing lead is implanted
in the atrium or ventricle depending on the chamber to be paced and sensed
Dual-Chamber Systemsbull Have Two Leadsbull One lead implanted in the
atrium bull One lead implanted in the
ventricle
METHODS OF PACING
Epicardialbull Used in patients that have undergone open heart surgerybull 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 chestand back of a patient and attached to anexternal pulse generator
METHODS OF PACING
Implanted pulse generatorbull A small device is surgically placed in a
subcutaneous pocket
Transvenousbull Via central line a lead is thread down to the RV
Transcutaneous Pacingbull Simple procedurebull ndash Pacing padsbull ndash Easy to applybull ndash Non invasivebull ndash Most monitor-defibrillators are also pacersbull ndash Can be one person procedurebull ndash Pads to chest wallbull ndash Attached to monitor-defibrillatorbull ndash Bridge until more permanent device can be
inserted
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Single-Chamber Systembull The pacing lead is implanted
in the atrium or ventricle depending on the chamber to be paced and sensed
Dual-Chamber Systemsbull Have Two Leadsbull One lead implanted in the
atrium bull One lead implanted in the
ventricle
METHODS OF PACING
Epicardialbull Used in patients that have undergone open heart surgerybull 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 chestand back of a patient and attached to anexternal pulse generator
METHODS OF PACING
Implanted pulse generatorbull A small device is surgically placed in a
subcutaneous pocket
Transvenousbull Via central line a lead is thread down to the RV
Transcutaneous Pacingbull Simple procedurebull ndash Pacing padsbull ndash Easy to applybull ndash Non invasivebull ndash Most monitor-defibrillators are also pacersbull ndash Can be one person procedurebull ndash Pads to chest wallbull ndash Attached to monitor-defibrillatorbull ndash Bridge until more permanent device can be
inserted
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
METHODS OF PACING
Epicardialbull Used in patients that have undergone open heart surgerybull 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 chestand back of a patient and attached to anexternal pulse generator
METHODS OF PACING
Implanted pulse generatorbull A small device is surgically placed in a
subcutaneous pocket
Transvenousbull Via central line a lead is thread down to the RV
Transcutaneous Pacingbull Simple procedurebull ndash Pacing padsbull ndash Easy to applybull ndash Non invasivebull ndash Most monitor-defibrillators are also pacersbull ndash Can be one person procedurebull ndash Pads to chest wallbull ndash Attached to monitor-defibrillatorbull ndash Bridge until more permanent device can be
inserted
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
METHODS OF PACING
Implanted pulse generatorbull A small device is surgically placed in a
subcutaneous pocket
Transvenousbull Via central line a lead is thread down to the RV
Transcutaneous Pacingbull Simple procedurebull ndash Pacing padsbull ndash Easy to applybull ndash Non invasivebull ndash Most monitor-defibrillators are also pacersbull ndash Can be one person procedurebull ndash Pads to chest wallbull ndash Attached to monitor-defibrillatorbull ndash Bridge until more permanent device can be
inserted
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Transcutaneous Pacingbull Simple procedurebull ndash Pacing padsbull ndash Easy to applybull ndash Non invasivebull ndash Most monitor-defibrillators are also pacersbull ndash Can be one person procedurebull ndash Pads to chest wallbull ndash Attached to monitor-defibrillatorbull ndash Bridge until more permanent device can be
inserted
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Transvenous Pacingbull Invasive
ndash Equipment intensendash Invasivendash Exposure to bloodndash Requires at least 2 peoplendash Directly into heartndash Quick in hands of experienced practitionerndash Wire into Right Ventriclendash Attached to Pulse Generator
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Types of pacemakersTemporary bull -Transvenous- pacing
wire via central line to RV under X rayusually bipolar ie with 2 electrodes at the end of wire
bull -Transthoracic-one electrode over cardiac apexother over right scapula or clavicle
bull -Epicardial Pacing
Permanent-bull a pulse generator is
implanted subcutaneouslyelectrodes usually unipolar ieone intracardiac electrodewith current returning to pacemaker via body
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Pacemaker Configurations
Position
I II III IV VParameter measured
Chamberspaced
Chambers sensed
Response to endogenous depolarization
Rate modulation
Anti tachycardia function
Possible values
O = None O = None O = None O = None O = None
A = Atrium
A = Atrium
I = Inhibited R = Rate response on
P = Pace
V = Ventricle
V = Ventricle
T = Triggered
S= Shock
D = Dual (A + V)
D = Dual (A + V)
D = Dual (I + T)
D = Dual
NASPE North American Society of Pacing and Electrophysiology BPEG British Pacing and Electrophysiology Group
bullFor external pulse generators only positions I II amp III apply
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Terminology
bull Atrial Tracking ndash A pacing mode in which the ventricles are paced in synchrony with sensed atrial eventsbull A-V Synchrony ndash The activation sequence of the heart in which the atria contract first and then after an appropriate delay the ventriclesbull Base Rate ndash The rate at which a pulse generator
emits a stimuli
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Terminology
bull Dual Chamber Pacing ndash Pacing in both the atria and ventricles to artificially restore the natural contraction sequence of the heartbull Overdrive pacing ndash Pacing the heart at a rate faster than the patientrsquos intrinsic rhythm to suppress a tachycardia to gain electrical control of the heart or to suppress PVCs
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Terminology
bull Asynchronous ndash Pacemaker which stimulates at a fixed preset rate independently of the electrical or mechanical activity of the heartbull Demand (inhibited) ndash Any pacemaker which after sensing a spontaneous depolarization withholds a pacing stimulusbull A-V Sequential ndash A dual chamber pacemaker which can pace and sense in both atria amp ventricles
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Terminology bull Tracking ndash Pacemaker behavior in whichventricular pacing is synchronized to sensedatrial activitybull Triggered ndash The opposite of inhibited(demand) A triggered pacemaker upondetecting a spontaneous depolarization or othersignal will deliver an electrical stimulus to theheart
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Pacing
bull The primary role of cardiac pacing is to augment or replace the hearts intrinsic electrical system
bull Cardiac pacing is repetitive stimulation of cardiac activity used to treat brady or tachyarrhythmias
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
bull Most modern units are Dual unitsworking in DDD mode providing atrial pacing in presence of atrial bradycardia amp ventricular pacing after atrial depolarisation if spontaneous ventricular beat is absent
bull Worldwide gt 250000 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
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Pacemaker Programmer
bull The programming computer allows telemetric communication with the implanted pulse generator and acts as an interface to the healthcare provider
bull 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 (eg heart rate trends and tachyarrhythmia documentation
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Assessment
bull Check monitorbull Check PULSEbull Check responsivenessbull Check BPbull Obtain 12 lead EKGbull Document pacer settings
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
AssessmentPost Transvenous Insertionbull Secure catheter ndash Usually sutured by the physicianbull Apply sterile dressingbull Secure pacing leads by looping them and taping
them outside the dressingbull Secure generator to patientbull Obtain CXR to verify lead placement and evaluate
for pneumothorax
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Assessmentbull Detailed examination of cardiovascular systembull Identification of pacemakerdetermination of
pacemaker modeprimary indication for pacingbull Details of when device implantedwhen amp where
it was last checked anatomical position of current active generator
bull Pulse generator- battery statusreset mode information amp confirmation of satisfactory thresholds
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Assessmentbull 12 lead ECG (1) All beats preceeded by a pacemaker
spikeassume 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
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Complications
bull Hemopneumothorax during insertionbull Bleeding at insertion sitebull Myocardial perforationbull Myocardial irritability gtgt dysrhythmiasbull Transient BBBbull Failure to achieve capture
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Electro magnetic interference
bull Sources of EMI are found most commonly in Hospital Environments
bull Sources of EMI that interfere with pacemaker operation include surgicaltherapeutic equip such as
bull Electrocauterybull Transthoracic defibrillationbull Extracorporeal shock-wave lithotripsybull Therapeutic radiation
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Electro magnetic interference
bull RF ablationbull TENS unitsbull MRI New technologies will continue to create
new unanticipated sources of EMIbull Cellular phones amp digital technology
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Electro magnetic interference
Sources of EMI are found more rarely inbull Home office and shopping environmentsbull Industrial environments with very high electrical
outputsbull Transportation systems with high electrical energy exposure or with high-powered radar and radio transmission ndash Engines or subway braking systems ndash Airport radar ndash Airplane enginesbull TV and radio transmission sites
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
MEDTRONIC 5388bull Dual Chambered Pacemaker
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Pacemaker ConfigurationsVOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Pacemaker ConfigurationsVVI
Indications
The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation)
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Pacemaker ConfigurationsAAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Pacemaker ConfigurationsDDD
Indications1 The combination of AV block and SSS2 Patients with LV dysfunction and LV hypertrophy
who need coordination of atrial and ventricular contractions to maintain adequate CO
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Problems with PacemakersFailure to Capture
Causes bull Threshold rise (electrolytes drugs)bull Lead dislodgementbull Lead fracturebull RV infarct
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Problems with PacemakersFailure to Pace
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Problems with PacemakersFailure to Sense
Braunwalds Heart Disease A Textbook of Cardiovascular Medicine 7th ed 2005
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Example 1
Ventricular sensed ventricular paced
Consistent with VVI
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Example 2
Atrial sensed ventricular paced
Consistent with DDD or VDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Example 3
Atrial paced
Consistent with AAI or DDD
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Example 4
Failure to Pace
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Example 5
Failure to Sense
The Alan E Lindsay ECG Learning Center httpmedstatmedutahedukwecg
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
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
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Paced Rhythm Recognition
AAI 60
Paced Rhythm Recognition
DDD 60 120
Paced Rhythm Recognition
DDD 60 120
Paced Rhythm Recognition
DDD 60 120
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Paced Rhythm Recognition
DDD 60 120
Paced Rhythm Recognition
DDD 60 120
Paced Rhythm Recognition
DDD 60 120
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Paced Rhythm Recognition
DDD 60 120
Paced Rhythm Recognition
DDD 60 120
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Paced Rhythm Recognition
DDD 60 120
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Summary of Basic Pacing ConceptsModulebull 1048673Pacing systems
bull 1048673Electrical conceptsbull 1048673Stimulation thresholdsbull 1048673Sensingbull 1048673Electromagnetic Interference (EMI)bull 1048673Rate responsebull 1048673NASPE BPEG Nomenclature
Thank you
Thank you
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