Temporary PacingTemporary Pacing

William H. Sauer, MDWilliam H. Sauer, MD

Road MapRoad Map

IndicationsIndicationsMethods for PlacementMethods for PlacementBasic ProgrammingBasic Programming

Road MapRoad Map

IndicationsMethods for PlacementMethods for PlacementBasic ProgrammingBasic Programming

IndicationsIndications

Bradycardia in the Setting of MIBradycardia in the Setting of MIBradycardia not related to MIBradycardia not related to MIPrevention of VT/VFPrevention of VT/VFProphylaxisProphylaxis

Slow Heart Rates peri MISlow Heart Rates peri MI

Mobitz II after an anterior MIMobitz II after an anterior MINew fascicular block and long PRNew fascicular block and long PRAlternating Bundle Branch BlockAlternating Bundle Branch BlockMedically Refractory Sinus Node Medically Refractory Sinus Node

DysfunctionDysfunctionThird Degree AV blockThird Degree AV block

Bradycardia not related to MIBradycardia not related to MI

Medically Refractory Medically Refractory Symptomatic BradycardiaSymptomatic Bradycardia

Third degree AV block with wide Third degree AV block with wide QRS escapeQRS escape

Prevention of VT/VFPrevention of VT/VF

TdP relies on bradycardia dependence TdP relies on bradycardia dependence (long-short sequence)(long-short sequence)

Long QT3 – bradycardia dependentLong QT3 – bradycardia dependentMMVT requiring frequent ATPMMVT requiring frequent ATP

Prophylactic ImplantProphylactic Implant

Patients with LBBB requiring Swan-Ganz Patients with LBBB requiring Swan-Ganz catheter placementcatheter placement

Cardioversion in the setting of SSSCardioversion in the setting of SSSNew BBB in the setting of acute New BBB in the setting of acute

endocarditisendocarditisPeri-operativelyPeri-operatively

Road MapRoad Map

IndicationsIndicationsMethods for PlacementBasic ProgrammingBasic Programming

Types of Temporary PacersTypes of Temporary Pacers

TranscutaneousTranscutaneousTransesophogealTransesophogealEpicardialEpicardialTransvenousTransvenous

Types of Temporary PacersTypes of Temporary Pacers

TranscutaneousTranscutaneousTransesophogealTransesophogealEpicardialEpicardial

Transvenous

EquipmentEquipment

7F introducer and prep kit7F introducer and prep kitMobile C-Arm FluoroscopyMobile C-Arm FluoroscopyPacing LeadPacing LeadExternal PacemakerExternal PacemakerSuture and TegadermSuture and Tegaderm

AccessAccess

Leave the subclavian vein alone – an EP Leave the subclavian vein alone – an EP will need this space to implant the will need this space to implant the permanent pacer or ICDpermanent pacer or ICD

Right IJ is easiest access to the right Right IJ is easiest access to the right ventricleventricle

Femoral Vein is next easiest to move a Femoral Vein is next easiest to move a non-deflectable catheter to the RVnon-deflectable catheter to the RV

Left IJ is last resortLeft IJ is last resort

The pacing leadThe pacing lead

The lead is a spear that will pierce the The lead is a spear that will pierce the heart – be gentleheart – be gentle

Balloon-tipped catheters are preferableBalloon-tipped catheters are preferableThe pacing port on the SGC is lethalThe pacing port on the SGC is lethalLeave a little bit of slack – but do not make Leave a little bit of slack – but do not make

the lead buckle in the heartthe lead buckle in the heart

Road MapRoad Map

IndicationsIndicationsMethods for PlacementMethods for PlacementBasic Programming

NBG Code ReviewNBG Code Review

IChamber

Paced

IIChamber

Sensed

IIIResponseto Sensing

IVProgrammableFunctions/Rate

Modulation

VAntitachy

Function(s)

V: Ventricle V: Ventricle T: Triggered P: Simpleprogrammable

P: Pace

A: Atrium A: Atrium I: Inhibited M: Multi-programmable

S: Shock

D: Dual (A+V) D: Dual (A+V) D: Dual (T+I) C: Communicating D: Dual (P+S)

O: None O: None O: None R: Rate modulating O: None

S: Single (A or V)

S: Single (A or V)

O: None

Single Chamber Timing Single Chamber Timing TerminologyTerminology

Lower rateLower rateRefractory periodRefractory periodBlanking periodBlanking periodUpper rateUpper rate

Lower Rate IntervalLower Rate Interval

Lower Rate Interval

VP VP VVI / 60

Defines the lowest rate the pacemaker will paceDefines the lowest rate the pacemaker will pace

Refractory PeriodRefractory Period

Lower Rate Interval

VP VP VVI / 60

Interval initiated by a paced or sensed Interval initiated by a paced or sensed eventevent

Designed to prevent inhibition by Designed to prevent inhibition by cardiac or non-cardiac eventscardiac or non-cardiac events

Refractory Period

Blanking PeriodBlanking Period

Lower Rate Interval

VP VP VVI / 60

The first portion of the refractory periodThe first portion of the refractory period Pacemaker is “blind” to any activityPacemaker is “blind” to any activity Designed to prevent oversensing pacing stimulusDesigned to prevent oversensing pacing stimulus

Blanking PeriodRefractory Period

VOO ModeVOO Mode

Blanking Period

VP VP

Lower Rate Interval

VOO / 60

Asynchronous pacing delivers output Asynchronous pacing delivers output regardless of intrinsic activityregardless of intrinsic activity

Rate = 60 bpm / 1000 msA-A = 1000 ms

APVP

APVP

V-AAV V-AAV

Atrial Pace, Ventricular Pace (AP/VP)Atrial Pace, Ventricular Pace (AP/VP)

Four “Faces” of Dual Chamber Four “Faces” of Dual Chamber PacingPacing

Rate = 60 ppm / 1000 msA-A = 1000 ms

AP VS

AP VS

V-AAV V-AAV

Atrial Pace, Ventricular Sense (AP/VS)Atrial Pace, Ventricular Sense (AP/VS)

Four “Faces” of Dual Chamber Four “Faces” of Dual Chamber PacingPacing

ASVP

ASVP

Rate (sinus driven) = 70 bpm / 857 msA-A = 857 ms

Atrial Sense, Ventricular Pace (AS/ VP)Atrial Sense, Ventricular Pace (AS/ VP)

V-AAV AV V-A

Four “Faces” of Dual Chamber Four “Faces” of Dual Chamber PacingPacing

Rate (sinus driven) = 70 bpm / 857 msSpontaneous conduction at 150 msA-A = 857 ms

ASVS

ASVS

V-AAV AV V-A

Atrial Sense, Ventricular Sense (AS/VS)Atrial Sense, Ventricular Sense (AS/VS)

Four “Faces” of Dual Chamber Four “Faces” of Dual Chamber PacingPacing

Dual Chamber Timing Dual Chamber Timing ParametersParameters

Lower rateLower rateAV and VA intervalsAV and VA intervalsUpper rate intervalsUpper rate intervalsRefractory periodsRefractory periodsBlanking periodsBlanking periods

Lower Rate Interval

APVP

APVP

Lower Rate Lower Rate

The lowest rate the pacemaker will pace the The lowest rate the pacemaker will pace the atrium in the absence of intrinsic atrial eventsatrium in the absence of intrinsic atrial events

DDD 60 / 120

APVP

ASVP

PAV SAV

200 ms 170 ms

Lower Rate Interval

AV IntervalsAV Intervals

Initiated by a paced or non-refractory sensed atrial Initiated by a paced or non-refractory sensed atrial eventevent Separately programmable AV intervals – SAV /PAVSeparately programmable AV intervals – SAV /PAV

DDD 60 / 120

APVP

ASVP

PAV SAV

200 ms 170 ms

Lower Rate Interval

AV IntervalsAV Intervals

Initiated by a paced or non-refractory sensed atrial Initiated by a paced or non-refractory sensed atrial eventevent Separately programmable AV intervals – SAV /PAVSeparately programmable AV intervals – SAV /PAV

DDD 60 / 120

Atrial Escape Interval (V-A Interval)Atrial Escape Interval (V-A Interval)

Lower rate interval– AV intervalV-A interval

Lower Rate Interval

APVP

APVP

AV Interval VA Interval

Atrial Escape Interval (V-A Interval)Atrial Escape Interval (V-A Interval)

The interval initiated by a paced or sensed The interval initiated by a paced or sensed ventricular event to the next atrial eventventricular event to the next atrial event

DDD 60 / 120PAV 200 ms; V-A 800 ms

200 ms 800 ms

Post Ventricular Atrial Refractory Period (PVARP)

Refractory PeriodsRefractory Periods

VRP and PVARP are initiated by sensed or VRP and PVARP are initiated by sensed or paced ventricular eventspaced ventricular events The VRP is intended to prevent self-inhibition such The VRP is intended to prevent self-inhibition such

as sensing of T-waves as sensing of T-waves The PVARP is intended primarily to prevent The PVARP is intended primarily to prevent

sensing of retrograde P wavessensing of retrograde P waves

AP

VPVentricular Refractory Period (VRP)

A-V Interval(Atrial Refractory)

Blanking PeriodsBlanking Periods

First portion of the refractory period-sensing is First portion of the refractory period-sensing is disableddisabled

AP

VP

AP

Post Ventricular Atrial Blanking (PVAB)

Post Atrial Ventricular Blanking

Ventricular Blanking (Nonprogrammable)

Atrial Blanking (Nonprogrammable)

Upper Rate Behaviors –Upper Rate Behaviors –Wenckebach and 2:1 BlockWenckebach and 2:1 Block

Lower rate

Atrial rate

Ven

tric

ula

r ra

te

Upper rate

Atrialtracking

PVARP

Upper Tracking Rate

Lower Rate Interval

{P Waves Blocked

AS AS

VPVP

SAV = 200 msPVARP = 300 ms

Thus TARP = 500 ms (120 ppm)

DDDLR = 60 ppm (1000 ms)

UTR = 100 bpm (600 ms)Sinus rate = 66 bpm (900 ms)

SAV

TARP

PVARP

Total Atrial Refractory Period Total Atrial Refractory Period (TARP)(TARP)

Sum of the AV Interval and PVARPSum of the AV Interval and PVARP

SAV

PVARP

Wenckebach OperationWenckebach Operation

Upper Tracking Rate

Lower Rate Interval {

AS AS AR APVPVP VP

TARPSAV PAV PVARP SAV PVARP

P Wave Blocked (unsensed or unused)

DDD Sinus rate = 109 bpm (550 ms) LR = 60 bpm (1000 ms) UTR = 100 ppm (600 ms)

SAV = 200 ms PAV = 230 ms PVARP = 300 ms

Prolongs the SAV until upper rate limit Prolongs the SAV until upper rate limit expiresexpires Produces gradual change in tracking rate ratioProduces gradual change in tracking rate ratio

TARP TARP

Wenckebach OperationWenckebach Operation

DDD / 60 / 120 / 310

Every other P wave falls into refractory and Every other P wave falls into refractory and does not restart the timing intervaldoes not restart the timing interval

Upper Tracking Limit

Lower Rate Interval {

{P Wave Blocked

AS AS

VPVPARAR

Sinus rate = 150 bpm (450 ms)PVARP = 300 ms SAV = 200 msTracked rate = 66 bpm (900 ms)

AV PVARP AV PVARP

TARP TARP

2:1 Block2:1 Block

2:1 Block2:1 Block

DDD / 60 / 120 / 310

CasesCases

Syncope - Indication for Syncope - Indication for Temporary Pacer?Temporary Pacer?

Asymptomatic - Indication for Asymptomatic - Indication for Temporary Pacer?Temporary Pacer?

Asymptomatic - Indication for Asymptomatic - Indication for Temporary Pacer?Temporary Pacer?

Asymptomatic when lying downAsymptomatic when lying down

Is This Normal Device Is This Normal Device Operation?Operation?

Is This Normal Device Operation? What Is This Normal Device Operation? What Feature Might You Want to Have Feature Might You Want to Have

Programmed On?Programmed On?

Is This Normal Device Is This Normal Device Operation? Operation?

Is This Normal Device Is This Normal Device Operation?Operation?