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Principles of Cardiac Pacing. Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery. Cardiac Conduction System. Cardiac Conduction System. Bundle of His. Right and Left Bundle Branches. Coronary Artery Disease - PowerPoint PPT Presentation
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Principles of Cardiac PacingPrinciples of Cardiac Pacing
Seoul National University Hospital
Department of Thoracic & Cardiovascular Surgery
Cardiac Conduction System
Bundle of His
Cardiac Conduction System
Right and Left
Bundle Branches
Factors Influencing Conduction System
• Coronary Artery Disease• Idiopathic Degeneration• Calcification• Endocarditis• Heart Surgery• RF Ablation
• Coronary Artery Disease• Idiopathic Degeneration• Calcification• Endocarditis• Heart Surgery• RF Ablation
Brief Indications of Cardiac Pacing
Choice of AAI/AAIR ModeChoice of AAI/AAIR ModeA. Indications 1. Symptomatic sinus node dysfunction with adequate AV conduction (AAI) 2. Hemodynamic enhancement through rate adjustment in patients who have bradycardia and symptoms of impaired cardiac output with adequate AV conduction (AAI) 3. 1 and 2, above, in the presence of chronotropic incompetence and an anticipated high level of physical activity, normal AV conduction, and little evidence for intrinsic or drug-induced AV block (AAIR)
B. Contraindications 1. Preexisting AV conduction delay or block or if decremental conduction is demonstrated at slow paced rates 2. Inadequate atrial pacing/sensing threshold 3. Inexcitable atrial tissue
Choice of VVI/VVIR ModeChoice of VVI/VVIR ModeA. Indications 1. Symptomatic bradyarrhythmia in the setting of no significant atrial hemodynamic contribution to cardiac output (eg. AF, SVT) (VVI) 2. No evidence of pacemaker syndrome (VVI) 3. Symptomatic bradycardia where pacing simplicity is a prime concern (eg. Senility, terminal D.) (VVI) 4. 1 and 2, above, with the presence of chronotropic incompetence and an anticipated high level of physical activity (VVIR)
B. Contraindications 1. Known pacemaker syndrome 2. Retrograde ventriculoatrial conduction with angina pectoris or congestive heart failure 3. Congestive heart failure where atrial contribution to cardiac output is important
Choice of DDD/DDDR ModeChoice of DDD/DDDR ModeA. Indications 1. Requirement for AV synchrony over a wide range of rates (DDD) 2. Complete heart block or sick sinus syndrome and stable atrial rates (DDD) 3. When simultaneous control of atrial and ventricular rates can be demonstrated to inhibit tachyarrhythmias directly or by programming changes (DDD) 4. 1 through 3, above, in patients with chronotropic incompetence and an anticipated moderate to high level of physical activity and in whom there is a stable atrial rhythm (DDDR)
B. Contraindications 1. Frequent or persistent supraventricular tachyarrhythmias, including atrial fibrillation and/or flutter 2. Inadequate atrial pacing/sensing threshold 3. Severe ischemic heart disease where angina is precipitated by an increased rate
Choice of DDI/DDIR ModeChoice of DDI/DDIR Mode
A. Indications 1. Patients who require dual-chamber pacing and who have frequent but not constant supraventricular arrythmias; atrial arrhythmias caused by competitive pacing are avoided because the atrial output is inhibited by an atrial or ventricular event (DDI) 2. 1, above, in patients with chronotropic incompetence and an anticipated moderate to high level of physical activity and in whom dual-chamber pacing is needed (DDIR)
B. Contraindications 1. Frequent or persistent supraventricular tachyarrhythmias, including atrial fibrillation and/or flutter 2. Inadequate atrial pacing/sensing threshold 3. Severe ischemic heart disease where angina is precipitated by an increased rate
• Sinus bradycardia
• Sinus arrest
• Sinoatrial exit block
• Atrial fibrillation with a slow ventricular
response
• Tachy-brady syndrome
Sick Sinus Syndrome
Sinus Bradycardia
Sinus Arrest & Sinoatrial Exit Block
Sinus Arrest
SA Exit Block
Atrial Fibrillation with Slow Ventricular Response
Tachycardia-Bradycardia Syndrome
Second Degree A-V Block
• Mobitz Type I (Wenckebach)• Mobitz Type II
Third Degree A-V Block
Congenital Third Degree A-V Block
NASPE / BPEG (NBG)Pacemaker Code
The NASPE/BPEG Generic (NBG) CodePosition
Category
LettersUsed
Manufac-turer’sDesignationOnly
I II III IV V
Chamber(s)Paced
Chamber(s)Sensed
Responseto Sensing
Programmability,rate modulation
Antitachy-arrhythmiaFunction(s)
O-None
P-SimpleProgrammable
M-Multi-Programmable
C-Communicating
R-Ratemodulation
O-None
A-Atrium
V-Ventricle
D-Dual(A+V)
S- Single(A or V)
S- Single(A or V)
O-None
A-Atrium
V-Ventricle
D-Dual(A+V)
O-None
T-Triggered
I-Inhibited
D-Dual(T+I)
O-None
P-Pacing(antitachy-arrhythmia)
S-Shock
D-Dual(P+S)
I=Pacing II=Sensing III=Sensing
Position
Category
LettersUsed
Manufac-turer’sDesignationOnly
I II III IV V
Chamber(s)Paced
Chamber(s)Sensed
Responseto Sensing
Programmability,rate modulation
Antitachy-arrhythmiaFunction(s)
O-None
P-SimpleProgrammable
M-Multi- Programmable
C-Communicating
R-Rate modulation
O-None
A-Atrium
V-Ventricle
D-Dual(A+V)
S- Single(A or V)
S- Single(A or V)
O-None
A-Atrium
V-Ventricle
D-Dual(A+V)
O-None
T-Triggered
I-Inhibited
D-Dual(T+I)
O-None
P-Pacing(antitachy-arrhythmia)
S-Shock
D-Dual(P+S)
The NASPE/BPEG Generic (NBG) Code
Position
Category
LettersUsed
Manufac-turer’sDesignationOnly
I II III IV V
Chamber(s)Paced
Chamber(s)Sensed
Responseto Sensing
Programmability,rate modulation
Antitachy-arrhythmiaFunction(s)
O-None
P-SimpleProgrammable
M-Multi- Programmable
C-Communicating
R-Rate modulation
O-None
A-Atrium
V-Ventricle
D-Dual(A+V)
S- Single(A or V)
S- Single(A or V)
O-None
A-Atrium
V-Ventricle
D-Dual (A+V)
O-None
T-Triggered
I-Inhibited
D-Dual(T+I)
O-None
P-Pacing(antitachy-arrhythmia)
S-Shock
D-Dual (P+S)
The NASPE/BPEG Generic (NBG) Code
Position
Category
LettersUsed
Manufac-turer’sDesignationOnly
I II III IV V
Chamber(s)Paced
Chamber(s)Sensed
Responseto Sensing
Programmability,rate modulation
Antitachy-arrhythmiaFunction(s)
O-None
P-SimpleProgrammable
M-Multi- Programmable
C-Communicating
R-Rate modulation
O-None
A-Atrium
V-Ventricle
D-Dual(A+V)
S- Single(A or V)
S- Single(A or V)
O-None
A-Atrium
V-Ventricle
D-Dual(A+V)
O-None
T-Triggered
I-Inhibited
D-Dual(T+I)
O-None
P-Pacing(antitachy-arrhythmia)
S-Shock
D-Dual(P+S)
The NASPE/BPEG Generic (NBG) Code
Position
Category
LettersUsed
I II III IV V
Chamber(s)Paced
Chamber(s)Sensed
Responseto Sensing
Programmability,rate modulation
Antitachy-arrhythmiaFunction(s)
O-None
P-SimpleProgrammable
M-Multi- Programmable
C-Communicating
R-Rate modulation
O-None
A-Atrium
V-Ventricle
D-Dual(A+V)
O-None
A-Atrium
V-Ventricle
D-Dual (A+V)
O-None
T-Triggered
I-Inhibited
D-Dual(T+I)
O-None
P-Pacing(antitachy-arrhythmia)
S-Shock
D-Dual(P+S)
The NASPE/BPEG Generic (NBG) Code
Manufac-turer’sDesignationOnly
S- Single(A or V)
S- Single(A or V)
Position
Category
LettersUsed
Manufac-turer’sDesignationOnly
I II III IV V
Chamber(s)Paced
Chamber(s)Sensed
Responseto Sensing
Programmability,rate modulation
Antitachy-arrhythmiaFunction(s)
O-None
P-SimpleProgrammable
M-Multi- Programmable
C-Communicating
R-Rate modulation
O-None
A-Atrium
V-Ventricle
D-Dual(A+V)
S- Single(A or V)
S- Single(A or V)
O-None
A-Atrium
V-Ventricle
D-Dual(A+V)
O-None
T-Triggered
I-Inhibited
D-Dual(T+I)
O-None
P-Pacing(antitachy-arrhythmia)
S-Shock
D-Dual(P+S)
The NASPE/BPEG Generic (NBG) Code
Position
Category
LettersUsed
Manufac-turer’sDesignationOnly
I II III IV V
Chamber(s)Paced
Chamber(s)Sensed
Responseto Sensing
Programmability,rate modulation
Antitachy-arrhythmiaFunction(s)
O-None
P-SimpleProgrammable
M-Multi- Programmable
C-Communicating
R-Rate modulation
O-None
A-Atrium
V-Ventricle
D-Dual(A+V)
S- Single(A or V)
S- Single(A or V)
O-None
A-Atrium
V-Ventricle
D-Dual (A+V)
O-None
T-Triggered
I-Inhibited
D-Dual(T+I)
O-None
P-Pacing(antitachy-arrhythmia)
S-Shock
D-Dual(P+S)
The NASPE/BPEG Generic (NBG) Code
Position
Category
LettersUsed
Manufac-turer’sDesignationOnly
I II III IV V
Chamber(s)Paced
Chamber(s)Sensed
Responseto Sensing
Programmability,rate modulation
Antitachy-arrhythmiaFunction(s)
O-None
P-SimpleProgrammable
M-Multi- Programmable
C-Communicating
R-Rate modulation
O-None
A-Atrium
V-Ventricle
D-Dual(A+V)
S- Single(A or V)
S- Single(A or V)
O-None
A-Atrium
V-Ventricle
D-Dual(A+V)
O-None
T-Triggered
I-Inhibited
D-Dual(T+I)
O-None
P-Pacing(antitachy-arrhythmia)
S-Shock
D-Dual(P+S)
The NASPE/BPEG Generic (NBG) Code
Pacing Systems Pacing Systems
