basic technical concepts in cardiac pacing
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Basic Technical Concepts in Basic Technical Concepts in Cardiac PacingCardiac Pacing
Dr D Sunil Reddy
Consultant Cardiologist
KIMS Hospital
TopicTopic
Electrical Stimulation of Cardiac Tissue
Myocardial StimulationMyocardial Stimulation
An artificial electrical stimulus excites cardiac tissue by the creation of an electrical field at the interface of the stimulating electrode and the myocardium
The electric field should be strong enough and should last long enough to initiate action potentials in the cells at the electrode-tissue interface
Myocardial StimulationMyocardial Stimulation
The AP’s at the site of stimulation result in AP’s in the neighbouring areas of the myocardium resulting in a wave of AP’s (depolarization) propagating away from the site of stimulation
Time (Milliseconds)100 200 300 400 500
Phase 2
Phase 1
Phase 3
Phase 4Tran
smem
bran
e Po
tent
ial
(Mill
ivol
ts)
-50
0
50
-100
Phas
e 0
Threshold
An artificial electrical stimulus excites cardiac tissue by the creation of an electrical field at the interface of the stimulating electrode and the myocardium
The electric field should be strong enough and should last long enough to initiate action potentials in the cells at the electrode-tissue interface
Electric Field – Current Density Electric Field – Current Density TheoryTheory
Electric Field Theory
– A Minimum Voltage/cm is required to trigger a self-propagating wave of depolarization
Current Density Theory
– A Minimum Current/cm2 is required to trigger a self-propagating wave of depolarization
Stimulation threshold is a function of Voltage/cm or Current/ cm2 that is induced in the myocardium beneath the stimulating electrode
The two theories are related by Ohm’s Law
The Implantable Pacemaker SystemThe Implantable Pacemaker System The Implantable Pulse Generator (IPG) : metal can
(titanium) containing electronics/battery & an electrode or lead connector header
Lead : Electrical connection between the pacemaker & the heart
The Pacemaker CircuitThe Pacemaker Circuit Stimulation of cardiac tissue using electric pulses
– IPG
– Lead – insulated current conductor (s) & electrodes to transmit pulses to heart tissue and measure or sense electrical activity in the heart
Heart
Lead
IPG
Completion of circuit through
Lead or Body tissue
A Unipolar Pacing System Contains a Lead with A Unipolar Pacing System Contains a Lead with Only One Electrode Within the Heart; In This Only One Electrode Within the Heart; In This
System, the Impulse:System, the Impulse:
Flows through the tip electrode (cathode)
Stimulates the heart
Returns through body fluid and tissue to the IPG (anode)
Cathode
Anode
-
Anode
Flows through the tip electrode located at the end of the lead wire
Stimulates the heart
Returns to the ring electrode above the lead tip
A Bipolar Pacing System Contains a Lead with Two A Bipolar Pacing System Contains a Lead with Two Electrodes Within the Heart. In This System, the Impulse:Electrodes Within the Heart. In This System, the Impulse:
Cathode
Tip electrode coil
Indifferent electrode coil
Lead ComponentsConnector
Lead body
Electrode(s)
Insulation Conductors
FixationThreshold Sensing
Connector Standards
Electrodes -- Fixation Mechanism
Passive Fixation Mechanism – Endocardial
– Tined – Finned
– Canted/curved
Electrodes – Fixation Mechanism
Active Fixation Mechanism – Endocardial
– Fixed screw
– Extendible/retractable
Electrodes -- Fixation Mechanism
Fixation Mechanism – Myocardial/Epicardial
– Stab-in
– Screw-in
– Suture-on
Single-Chamber SystemSingle-Chamber System
The pacing lead is implanted in the atrium or ventricle, depending on the chamber to be paced and sensed
One lead implanted in the atrium and one in the ventricle
Dual-Chamber Systems Have Two Leads:Dual-Chamber Systems Have Two Leads:
A pacing system can be thought of a standard electrical circuit:
The pacemaker supplies the voltage.
Current (electrons) flow down the
conductor to the lead tip or cathode (-)
Where the lead tip touches the myocardium, electrical resistance is
produced.
The current then flows through the body tissues to the anode (+) and
back to the battery.
All of these things are required for current to flow.
Pacing Circuit ParametersPacing Circuit Parameters
Voltage
Current
Impedance (resistance)
Energy
VoltageVoltage
Pushes electrons through an electric circuit resulting in electric current through the circuit
VoltageVoltage
Voltage is the force or “push” that causes electrons to move through a circuit
In a pacing system, voltage is:
– Measured in volts
– Represented by the letter “V”
– Provided by the pacemaker battery
– Often referred to as amplitude
CurrentCurrent
Current is the flow of charge or electrons through a circuit
CurrentCurrent
The flow of electrons in a completed circuit
In a pacing system, current is:
– Measured in mA (milliamps)
– Represented by the letter “I”
– Determined by the amount of electrons that move through a circuit
Resistance or ImpedanceResistance or Impedance
Opposition offered by a circuit to the flow of current
ImpedanceImpedance
The opposition to current flow in a circuit
In a pacing system, impedance is:
– Measured in ohms
– Represented by the letter “R” (for numerical values)
– The measurement of the sum of all resistance to the flow of current
Ohm’s LawOhm’s Law
Voltage = Current X Resistance
Current = Voltage Resistance
Resistance = Voltage Current
The Pacemaker StimulusThe Pacemaker Stimulus
Time
5 Volts 5 Volts 0.5 ms
1 sec
Pacing Stimulus Voltage or Amplitude – 5 Volts
Pulse Width – 0.0005 seconds or 0.5 milliseconds
Pacing Rate – One stimulus per second or 60 stimuli (beats) per minute
Vol
tage
The Pacing PulseThe Pacing Pulse
t
Pacing Pulse
Pulse Duration (Width)
Out
put V
olta
ge
V = Pulse Amplitude in Volts (V) (say 2.5 V)
t = Pulse Duration or Width in milliseconds (ms) (say 0.5 ms)
R = Impedance of Pacing Circuit (ohms) (say 500 ohms)
I = V/R = Current through pacing circuit (mA) = 2.5 V/ 500 ohms = 0.005 A = 5 mA
E = Energy supplied by Pulse to the Pacing Circuit and Cardiac Tissue = V . I . t = I2Rt = V2t/R = 2.5 V . 5 mA . 0.5 ms = 6.25 micro Joules
V
t
Stimulation ThresholdStimulation Threshold
Pacing Voltage Threshold – The minimum pacing voltage at any given pulse width required to consistently achieve myocardial depolarization outside the heart’s refractory period
Loss of Capture
The Strength-Duration RelationThe Strength-Duration Relation
The intensity of an electrical stimulus (Energy, Voltage, Current, Charge) required to capture (non-refractory) cardiac tissue is dependent on the duration for which the electrical stimulus is applied (i.e. pulse width)
The Voltage-Strength Duration The Voltage-Strength Duration CurveCurve
Stimulus Voltage & Pulse Width have an exponential relationship
At short pulse widths (<0.25 ms)the curve rises sharply (i.e. small reductions in pulse width result in large increases in the voltage threshold)
At long pulse widths (>1.0 ms)the curve is flat (i.e. the voltage threshold does not reduce with increasing pulse width) Duration
Pulse Width (ms)
.50
1.0
1.5
2.0
.25St
imul
atio
n Th
resh
old
(Vol
ts)
0.25 1.0 1.5
Capture
Rheobase & ChronaxieRheobase & ChronaxieRheobase Voltage = Voltage Threshold at infinite Pulse widths (e.g. 2 ms) – also known as fundamental threshold
Chronaxie Point = Pulse Width threshold at twice the rheobase voltage (i.e. 1 V & 0.3 ms)
Energy of Pacing PulseAt rheobase = 0.5V. 2ms. 1mA = 1 MicroJoule
At Chronaxie = 1V. 0.3 ms. 2mA = 0.6 MicroJoules
At PW=0.25 ms, = 1.5V. 0.25ms. 3mA = 1.125 MicroJoules
The chronaxie point approximates the point of minimum threshold energy on the Strength-Duration Curve
DurationPulse Width (ms)
Stim
ulat
ion
Thre
shol
d (V
olts
)
0.2 0.6 1.0
Energy Strength Duration Curve
Capture
0.4
0.5
1.0
2.0
0.8 1.2 1.4
Rheobase Voltage
Chronaxie Point
Goals of Pacemaker Output Goals of Pacemaker Output ProgrammingProgramming
Consistent capture & Patient Safety is ensured
Battery drain minimized, Pacemaker longevity maximized
Programming Chronic Pacemaker Programming Chronic Pacemaker OutputOutput
DurationPulse Width (ms)
Stim
ulat
ion
Thre
shol
d (V
olts
)
0.2 0.6 1.0
Energy Strength Duration Curve
• Capture
Adequate Safety Margin while minimizing Pulse Energy
Operate around the chronaxie point
Programming long pulse widths (& low Voltages) increases Pulse energy but hardly increases safety margin
Programming high voltages (with short Pulse widths) increases Pulse energy but hardly increases safety margin
For a 2 times safety margin : Output = 2 x chronaxie voltage at chronaxie pulse width (2V, 0.35 ms)
Output = 3 x pulse duration threshold at twice chronaxie voltage (2V, 0.51 ms)
0.4
0.5
1.0
2.0
0.8 1.2 1.4
Rheobase
Chronaxie
Determination of Stimulation Determination of Stimulation Threshold during Implant or Follow-upThreshold during Implant or Follow-up
Pace the heart at
– Rate higher than sinus or intrinsic rate
– Stimulus amplitude and pulse width that ensure capture (usually 5 V and 0.5 ms)
Gradually reduce stimulus amplitude while maintaining pulse width constant till capture is lost
The Stimulation threshold is specified by the minimum stimulus amplitude at which capture consistently occurs at a given stimulus pulse width
Programming Pacemaker OutputProgramming Pacemaker Output
Acute – Immediately post-implant
Chronic – Approx. 6 to 8 weeks post implant
Goal : To ensure consistent capture despite potential changes in the SD curve while minimizing the energy delivered by the pulse
Evolution of Pacing ThresholdEvolution of Pacing ThresholdV
olta
geTh
resh
old
(V)
Observation Time (weeks)
Acute Phase
Chronic Phase
Safety Margin
6
5
4
3
2
1
0 4 8 12 16
Programmable ParametersProgrammable Parameters
Pacemaker Pulse Output or Amplitude
– 0.5 V, 1.0 V, 1.5 V…., 7.5 V
Pacemaker Pulse Width
– 0.03, 0.06, …., 0.25, 0.5,…, 1.0 milliseconds
Pacing Impedance - ConsiderationsPacing Impedance - Considerations
Maximize Pacemaker Longevity
– Reduce current drain
– Maintain relatively high impedance
Ensure consistent capture
– Appropriate voltage & current are available at the electrode-tissue interface required to stimulate tissue
I pacing
Components of Pacing ImpedanceComponents of Pacing Impedance
Rcoil
Zpolarisation -electrode tissue
interface
Rtissue
Electrode
Tissue
Interface
Pulse GeneratorV pulse
I pacing
RRcoil - coil - Lead Conductor ResistanceLead Conductor Resistance
– Lead Conductor Impedance
• Reduces the voltage & energy available at the tissue for pacing
• Generates waste heat
• Designed to be low
conductorresistance
Conductor ResistanceConductor Resistance
Total Coil Voltage Voltageimpedance resistance at tip loss
()() (V) %
600 50 2.3 8.3
750 200 1.8 26.7
1200 650 1.1 54.2
1200 50 2.4 4.2
Output Voltage = 2.5 V
Impact of conductor coil resistance upon available tip electrode voltage
Conductor Resistance
V mV2.5 2500
Total imp 600
Current I =V/R 4.166666667 mAConductor imp 50
Voltage drop V = IR 208.3333333 mV0.208333333 V
What is the Polarization Effect – Polarization What is the Polarization Effect – Polarization Impedance ?Impedance ?
As the pacing pulse begins, electrons from the pacemaker battery flow to the lead tip and positively charged ions from the tissue are attracted to the lead tip.
Initially, the movement of these negatively charged ions results in the flow of current from the electrode into the myocardium.
As the pacing pulse continues, positively charged ions surround the electrode tip. This produces a positively charged layer on the electrode called polarization. Polarization can impede current flow from the electrode into the tissue.
Polarization Impedance & Polarization Impedance & Electrode Surface AreaElectrode Surface Area
As electrode surface area goes up
– Polarization impedance decreases
As electrode surface area goes down
– Polarization impedance increases
Polarization ImpedancePolarization Impedance
Pacing Pulse
Polarization
Factors affecting Polarization Factors affecting Polarization ImpedanceImpedance
Pulse Width
Surface area of the electrode tip
– Larger the surface area – Lower the Polarization
Electrode – Tissue Interface Electrode – Tissue Interface ImpedanceImpedance
Resistance to current flow from body tissue at the electrode-tissue interface
Electrode – Tissue Interface Electrode – Tissue Interface ImpedanceImpedance
Smaller the surface area of the tip electrode, the higher the current density (or electric field strength) at the electrode-tissue interface
The higher the field strength, the greater the pacing efficiency & lower the threshold
Electrode – Tissue Interface Electrode – Tissue Interface ImpedanceImpedance
Smaller the geometric size of the tip electrode, the higher the resistance between electrode and tissue
Paci
ng Im
peda
nce
(Ohm
s)
0
500
1000
1500
0 1 2 3 4 5.5 6
Geometric Tip Electrode Surface Area (mm2)
Size = Impedance
The Ideal Stimulating ElectrodeThe Ideal Stimulating Electrode
Needs large surface area to reduce Polarization Impedance
Needs small size to maximize Electric Field Strength and Stimulation Efficacy
Needs small size to maximize Electrode-tissue resistance and minimize pacemaker current drain
Electrodes -- Surface StructureElectrodes -- Surface Structure
Porous Electrode Surface
CapSure® 8.0 mm2
Porous Electrode
CapSure® SP Novus5.8 mm2 Platinized Porous Electrode
CapSure® Z Novus1.2 mm2 Platinized Porous Electrode
15KV x2500 12.0V MDT
Analogy:Lead with low impedance and poor efficiency
Lead Impedance I
Lead Impedance II
(Conductor-) Resistance
Analogy:Lead with high impedance in the conductor and poor efficiency
Lead Impedance III
Analogy:Lead with big tip-tissue impedance low conductor impedance and increased efficiency
The Chronic Virtual ElectrodeThe Chronic Virtual Electrode
IMPLANT CHRONIC(8 weeks or longer)
ExcitableCardiacTissue
Non-ExcitableFibroticTissue
ExcitableCardiacTissue
Evolution of Pacing ThresholdEvolution of Pacing ThresholdV
olta
geTh
resh
old
(V)
Observation Time (weeks)
Acute Phase
Chronic Phase
Safety Margin
6
5
4
3
2
1
0 4 8 12 16
Electrodes -- Steroid ElutionElectrodes -- Steroid Elution
Tines forStable Fixation
Silicone Rubber PlugContaining Steroid
Porous, Platinized Tipfor Steroid Elution
Type - Steroid in matrix
Electrodes -- Steroid ElutionElectrodes -- Steroid Elution Effect of Steroid on Stimulation Thresholds
Pulse Width = 0.5 msec
03 6
Implant Time (Weeks)
Textured Metal Electrode
Smooth Metal Electrode
1
2
3
4
5
Steroid-Eluting Electrode
0 1 2 4 5 7 8 9 10 11 12
Vol
ts
Factors that affect Stimulation Factors that affect Stimulation ThresholdThreshold
Eating, Sleeping, Exercise, Medications, Changes in Cardiac condition – 30 to 50 % during the day
Drugs e.g. Steroids reduce stimulation threshold by reducing inflammation
Sympathomimetic drugs decrease threshold
Amiodarone, Class I A (quinidine, procainamide), Class I B (Mexilitene)
Hypokalemia increases threshold (diuretics)
Hypocalcemia increases threshold
Hypoxia & Hypercapnia – Increase threshold
Electrolyte imbalance & pH e.g. acidosis and alkalosis increase threshold
Typical Pacing Circuit Typical Pacing Circuit ImpedancesImpedances
300 to 1200 ohms
May be measured at implant time with a Pacing System Analyzer (PSA) at implant time
May be measured through telemetry with a pacemaker programmer
Pacing Impedance Values Will Change Due Pacing Impedance Values Will Change Due to:to:
Insulation breaks
Wire fractures
An Insulation Break Around the Lead Wire An Insulation Break Around the Lead Wire Can Cause Impedance Values to FallCan Cause Impedance Values to Fall
Insulation breaks expose the wire to body fluids which have a low resistance and cause impedance values to fall
Current drains through the insulation break into the body which depletes the battery
An insulation break can cause impedance values to fall below 300
Insulation break
Decreased resistance
A Wire Fracture Within the Insulating Sheath A Wire Fracture Within the Insulating Sheath May Cause Impedance Values to RiseMay Cause Impedance Values to Rise
Impedance values across a break in the wire will increase
Current flow may be too low to be effective
Impedance values may exceed 3,000
Lead wire fracture
Increased resistance
Unipolar &Bipolar StimulationUnipolar &Bipolar Stimulation
+
-
+ -
-
+ Anode is IPG Case
Cathode is lead tip electrode
-
+ Anode is lead proximal electrode
Cathode is lead tip electrode
Unipolar & Bipolar StimulationUnipolar & Bipolar Stimulation
Unipolar Stimulation– Large Stimulus Artifact
Bipolar Stimulation – Small Stimulus Artifact
There is a greater chance of pacemaker pocket muscle stimulation with Unipolar Stimulation
The Pacemaker BatteryThe Pacemaker Battery
Pacemakers typically use Lithium-Iodide batteries
Most LiI batteries have a Beginning of Life (BOL) value of 2.8 volts
Recommended Replacement Time (ERI/RRT) value of 2.6 V
End of Service (EOL/EOS) value of 2.5 V
As battery depletes its internal resistance goes up – (BOL = 100 ohms , EOL > 5000 ohms )
Recommended Replacement Time RRT (ERI)
2.8V-
2.6V-
2.5V-
BOL
RRT 2.6V
EOS 2.5V
Time
Lithium Iodine Battery depletion
BOL – Beginning of LifeRRT – Recommended Replacement TimeEOS - End of Service
Battery LifeBattery Life Battery Life
– Battery Life = Battery Capacity/Current Drain
– 2.0 Ah/25microamps = 80,000 hours = 9.3 years
Battery properties
– Reliability – no premature failure
– High volumetric energy density – Small battery volume with high storage capacity
– Low self-discharge rate
– High hermiticity – no gas generation during operation
Pacemaker LongevityPacemaker Longevity
Energy = (V.I.t) = (V2/R) . t Joules
Reducing V by a factor of 2 reduces E by a factor of 4
Increasing Z by a factor by 2 reduces E by a factor of 2
Pacemaker LongevityPacemaker Longevity
High Outputs and pulse widths are the primary cause for reduced pacemaker longevity
• Output Voltages higher than the Battery Voltage (2.8 V) require the use of voltage doublers that use high battery energy
• Long Pulse Widths Reduce pacing efficiency due to increased polarization impedance
Sensing Intracardiac Electrical Sensing Intracardiac Electrical ActivityActivity
A Pacemaker Must Be Able to Sense and Respond to Cardiac Rhythms
Accurate sensing enables the pacemaker to determine whether or not the heart has created a beat on its own
The pacemaker is usually programmed to respond with a pacing impulse only when the heart fails to produce an intrinsic beat
Intracardiac Electrical SignalsIntracardiac Electrical Signals
Electrical currents that arise in the myocardium during depolarization and repolarization
A myocardial electrode - records voltage difference wrt reference electrode when the myocardium under the electrode undergoes depolarization or repolarization
The electrical activity measured by such an electrode (which is in direct contact with cardiac tissue) – local tissue electrical activity- Intracardiac Electrogram or EGM
Sensing the EGMSensing the EGM
Depolarization Wave
Processed by Processed by DeviceDevice
The EGM Signal
The signal from a depolarization wave passing between two electrodes
Intracardiac ElectrogramIntracardiac Electrogram
R wave of the EGM indicating depolarisation of cardiac ventricular tissue at lead tip – Roughly corresponds to R wave of the ECG that represents depolarisation of the ventricles
T wave of the EGM indicating repolarisation of cardiac ventricular tissue at lead tip – Roughly corresponds to T wave of the ECG that represents repolarisation of the ventricles
Voltage Deflections of the Sensed Voltage Deflections of the Sensed EGM in a PacemakerEGM in a Pacemaker
Pacemaker
Stimulus
Paced R wave
Post-pace T wave
Intrinsic R wave
T wave corresponding to intrinsic R wave
Undersensing . . .
Pacemaker does not “see” the intrinsic beat, and therefore does not respond appropriately
Intrinsic beat not sensed
Scheduled pace delivered
VVI / 60
Oversensing
An electrical signal other than the intended P or R wave is detected
Marker channel shows
intrinsic activity...
...though no activity is present
VVI / 60
Measured by:
– Amplitude
• Peak-to-peak measurement (height)
of deflection
• Measured in Millivolts (mV)– Slew Rate
• Speed of deflection change over time
• Measured in volts per second (V/s)
EGM amplitude
EGM Amplitude & Slew RateEGM Amplitude & Slew Rate
Amplitude of the EGM R wave = dV
Slew Rate of the EGM R wave= dV/dt
EGM amplitude & slew rate – ideal values
Atrium Ventricle
Slew Rate 0.5 volts/sec 0.75 volts/secAmplitude >1.5 mV >5.0 mV
Which of the these complexes shows the highest slew rate?
a)1 b)2 c)3 d)4
Frequency (Hz)
Accurate Sensing Requires That Extraneous Signals Be Filtered Out
Effect of Filtering on EGMEffect of Filtering on EGM
FILTER
•Filters out frequencies below 5 Hz (T waves) and above 50 Hz (myopotentials)
•Enhances frequencies between 10 Hz and 50 Hz (R waves) with maximum enhancement at around 30 Hz frequency
• Low Slew Rate implies Low Frequency implies Less enhancement due to filtering
LevelDetector
Level Detector or Sensitivity Level Detector or Sensitivity SettingSetting
This is a value specified to the pacemaker in millivolts through programming.
All ventricular EGM deflections AFTER FILTERING that exceed the sensitivity setting will be identified by the pacemaker as intrinsic R waves
The typical sensitivity setting that is programmed for Ventricular sensing is 2.5 mV
Sensitivity The Greater the Number, the Less Sensitive the Device to Intracardiac Events
SensitivityAm
plit
ude
(mV)
Time
5.0
2.5
1.25
Sensitivity SettingSensitivity Setting
Sensitivity settings less than 2.5 mv – High sensitivity – can lead to oversensing
Sensitivity settings greater than 2.5 mV – Low sensitivity – can lead to undersensing
Am
plitu
de (m
V)
Am
plitu
de (m
V)
Time Time
5.0
2.5
1.25
5.0
2.5
1.25
Factors That May Affect Sensing Are:
Lead polarity (unipolar vs. bipolar)
Lead integrity
– Insulation break
– Wire fracture EMI – Electromagnetic Interference
Unipolar Sensing
Produces a large potential difference due to:
– A cathode and anode that are farther apart than in a bipolar system
_
Bipolar Sensing
Produces a smaller potential difference due to the short interelectrode distance
– Electrical signals from outside the heart such as myopotentials are less likely to be sensed
An Insulation Break May Cause Both Undersensing or Oversensing
Undersensing occurs when inner and outer conductor coils are in continuous contact
– Signals from intrinsic beats are reduced at the sense amplifier and amplitude no longer meets the programmed sensing value
–
Oversensing occurs when inner and outer conductor coils make intermittent contact
– Signals are incorrectly interpreted as P or R waves
Wire Fracture Can Cause Both Undersensing and Oversensing
Undersensing occurs when the cardiac signal is unable to get back to the pacemaker – intrinsic signals cannot cross the wire fracture
Oversensing occurs when the severed ends of the wire intermittently make contact, which creates potentials interpreted by the pacemaker as P or R waves
Fracture in one filament leads to an increase in resistance
Electromagnetic Interference
Interference is caused by electromagnetic energy with a source that is outside the body
Electromagnetic fields that may affect pacemakers are radio-frequency waves
– 50-60 Hz are most frequently associated with pacemaker interference
Few sources of EMI are found in the home or office but several exist in hospitals
Oversensing May Occur When EMI Signals Are Incorrectly Interpreted as P Waves or R Waves
Pacing rates will vary as a result of EMI:
– Rates will accelerate if sensed as P waves in dual-chamber systems (P waves are “tracked”)
– Rates will be low or inhibited if sensed in single-chamber systems, or on ventricular lead in dual-chamber systems
Electrocautery is the Most Common Hospital Source of Pacemaker EMI
Outcomes
– Oversensing–inhibition
– Undersensing (noise reversion)
– Power on Reset
– Permanent loss of pacemaker output
(if battery
voltage is low)
Precautions
– Reprogram mode to VOO/DOO, or place a magnet over device
– Strategically place the grounding plate
– Limit electrocautery bursts to 1-second burst every 10 seconds
– Use bipolar electrocautery forceps
Transthoracic Defibrillation Outcome
– Inappropriate reprogramming
of the pulse
generator (POR)
– Damage to
pacemaker circuitry Precautions
– Position defibrillation paddles apex-posterior (AP) and as far from the pacemaker and leads as possible
Magnetic Resonance Imaging (MRI) is Generally Contraindicated in Patients with Pacemakers
Outcomes
– Extremely high pacing rate
– Reversion to asynchronous pacing
Precautions
– Program pacemaker output low enough to create persistentnon-capture, ODO or OVO mode
Radiation Energy May Cause Permanent Damage
Certain kinds of radiation energy may cause damage to the semi-conductor circuitry
– Ionizing radiation used for breast or
lung cancer therapy Damage can be permanent and requires
replacement of the pacemaker
Therapeutic Radiation May Cause Severe Damage
Outcomes:
– Pacemaker circuit damage
– Loss of output
– “Runaway”
Precautions:
– Keep cumulative radiation absorbed by the pacemaker to less than 500 rads; shielding may be required
– Check pacemaker after radiation sessions for changes in pacemaker function (can be done transtelephonically)
Refractory & Blanking PeriodsRefractory & Blanking Periods
Voltage Deflections of the Sensed Voltage Deflections of the Sensed EGM in a PacemakerEGM in a Pacemaker
Pacemaker
Stimulus
Paced R wave
Post-pace T wave
Intrinsic R wave
T wave corresponding to intrinsic R wave
2.5 mV
Refractory PeriodRefractory Period
Refractory Period Refractory Period Refractory Period
NO SENSING NO SENSING NO SENSING
Refractory PeriodRefractory Period
A programmable period immediately following a pacemaker stimulus or a sensed intrinsic R wave during which the pacemaker does not react to sensed events
To prevent repeated sensing of the same intrinsic R wave
To prevent misidentification of T waves as intrinsic R waves
To prevent misidentification of effects of pacemaker stimulus/evoked R wave
Usually programmed to 325 ms
To Prevent Oversensing
Afterpotential due to PolarizationAfterpotential due to Polarization
Afterpotential
Blanking PeriodBlanking Period
The first portion of every refractory period
Pacemaker is “blind” to any activity and no events can be sensed
Designed to prevent oversensing of pacing stimulus & after-potential
Blanking PeriodRefractory Period
Conductor Tip Electrode Insulation Connector Pin
Pacing Lead ComponentsPacing Lead Components
Conductor Connector Pin Insulation Electrode
ConnectorConnector
Purpose
– Connects lead to IPG, and provides a conduit to:• Deliver current from IPG to lead • Return sensed cardiac signals to IPG
Connector
Connector -- IS-1 StandardConnector -- IS-1 Standard
IS-1 Standard Connectors
Sizes Prior to IS-1 Standard
– 3.2 mm low-profile connectors
– 5/6 mm connectors
Insulation -- TypeInsulation -- Type
Insulation Types
– Silicone
– Polyurethane
– Fluoropolymers (PTFE, ETFE)
Electrodes -- Fixation MechanismElectrodes -- Fixation Mechanism
Passive Fixation Mechanism – Endocardial
– Tined – Finned
– Canted/curved
Electrodes – Fixation MechanismElectrodes – Fixation Mechanism
Active Fixation Mechanism – Endocardial
– Fixed screw
– Extendible/retractable
Electrodes -- Fixation/VisualizationElectrodes -- Fixation/Visualization
Fluoroscopic Visual Quality of Active Fixation Leads
SureFixCapSureFix®
Extended Retracted Fixed Screw
space
Electrodes -- Fixation MechanismElectrodes -- Fixation Mechanism
Fixation Mechanism – Myocardial/Epicardial
– Stab-in
– Screw-in
– Suture-on
Battery CapacityBattery Capacity
A battery is a reservoir of electrical charge measured in Coulombs
Current is the amount of charge delivered per unit time – 1 Ampere = 1 Coulomb per second
– 1 Coulomb = 1 Ampere x 1 second
Qc = Battery Capacity is specified as the quantity of charge it can deliver in AmpereHours (0.5 to 3 Amperehours)
Battery LifeBattery Life Battery Life
– Battery Life = Battery Capacity/Current Drain
– 2.0 Ah/25microamps = 80,000 hours = 9.3 years
Battery properties
– Reliability – no premature failure
– High volumetric energy density – Small battery volume with high storage capacity
– Low self-discharge rate
– High hermiticity – no gas generation during operation
On the figure, the zone of non capture is indicated by which number?
a)1b)2c)3d)4
Which of the following output settings best represents the Chronaxie point on the strength-duration curve when the Rheobase is 0.5V @ 1.5ms?
a) 0.5V @ 1.5ms
b) 1.0V @ 0.5ms
c) 1.5V @ 0.1 ms
d) 2.0V @ 0.05ms
Sensing
Sensing is the ability of the pacemaker to “see” when a natural (intrinsic) depolarization is occurring
– Pacemakers sense cardiac depolarization by measuring changes in electrical potential of myocardial cells between the anode and cathode
Intrinsic deflection on an EGM occurs when a depolarization wave passes directly under the electrodes
Two characteristics of the EGM are:
– Signal amplitude
– Slew rate
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