Pacemaker Pacemaker Follow-upFollow-up

Alpay Çeliker MD.

Hacettepe University

Department of Pediatric Cardiology

3rd International Summer School on CardiacArrhythmias, 9-12 September, Eskişehir

OrganizationOrganization

Regular follow-up schedule Pacemaker record files X-ray ECG Telemetry units

Pacemaker Follow-up:Pacemaker Follow-up:ObjectivesObjectives

Adjust the pacing system

Maximize the benefits of pacing therapy

Predict impending pacemaker system failure before the patient is at risk

Ascertain the nature of malfunction

Look for accompanying complications

PATIENT

TELEMETRY ECG&TELE

PHYSICAL EXAM

• THRESHOLDS• INTRINSIC AMPLITUDES• PACEMAKER DEPENDENCY• PACING RATIO• HISTOGRAMS

• PACING EFFICACY• LEAD PROBLEMS

HOLTER, EXERCISE TEST

• EXERCISE PERFORMANCE• MAXIMUM HEART RATE• DETECT CAPTURE AND SENSING PROBLEMS

ECHO

Pacemaker Follow-upPacemaker Follow-up

Patient evaluationPatient evaluation History Physical examination Chest x-ray Echocardiography

Pacing system evaluationPacing system evaluation Surface ECG Telemetric control of pacemaker Holter monitoring Treadmill testing

HistoryHistory Palpitations

Rapid ventricular rate, PMT, intrinsic tachycardia

Weakness, fatigue, malaise, dyspnea Pacemaker syndrome, capture failure, inappropriate

programming, cardiac or pulmonary disease

Hiccups Syncope, presyncope

Pacemaker syndrome, capture problem, inhibition due to oversensing

Cough, chest pain

Radiologic EvaluationRadiologic Evaluation

Pacemaker Interrogation Administrative data verificationAdministrative data verification

Name, implant date Programmed data controlProgrammed data control Examine the pacing&sensing parametersExamine the pacing&sensing parameters

Capture threshold Voltage measurements Battery&lead measurements

Overview the memorized dataOverview the memorized data

Capture ThresholdsCapture Thresholds

Automatic or manual measurements

Voltage or pulse width thresholds

Pacing rate > spontan rate during test

Test during coughing and deep respiration to detect malfunction

Absence of PM Stimuli or Absence of PM Stimuli or CaptureCapture

Intrinsic rate > pacing rate Hysteresis Very tiny bipolar stimuli Lead problems

Fracture, loose connection

Pulse generator problems EOL, failure

Electromagnetic interference Oversensing

Atrial NoncaptureAtrial Noncapture

Ventricular NoncaptureVentricular Noncapture

Sensing ThresholdsSensing Thresholds

Automatic or manual measurements

Print-out of intracardiac electrocardiogram

Needs for spontaneous atrial or ventricular rhythm

UndersensingUndersensing

UndersensingUndersensing Low amplitude EGM due to poor lead

position Lead dislodgement Lead malfunction Metabolic or toxic causes Development of new bundle branch

block Myocardial infarciton near the electrode

tip

OversensingOversensing

Causes of OversensingCauses of Oversensing VentricularVentricular

T wave Crosstalk Myopotentials False signals

AtrialAtrial Far-field R wave Myopotentials False signals

Change in Pacing RateChange in Pacing Rate

Battery depletion Runaway pacemaker Component failure Oversensing External effects on battery Phantom or wrong programming

Signs of Lead FractureSigns of Lead Fracture

No stimuli Stimuli without capture Oversensing of false signals Permanent or intermittant high lead

impedance Maneuvers X-ray

Testing of Specific Testing of Specific FunctionsFunctions

Check for crosstalk

Evaluate the VA interval

Examine rate adaptive parameters

Hysteresis, sleep rate

Automatic mode switching

Histogram settings

Rate Adaptive Pacemaker Rate Adaptive Pacemaker

Rate HistogramRate Histogram

Assess rate response settings

Assess high rate events

Evaluate percent pacing versus sensing

Determine if a change in disease state condition

has occurred

Atrial Pace/sense HistogramAtrial Pace/sense Histogram

Physical ExaminationPhysical Examination

Pacing System

Pocket Vascular System Leads

•Infection•Erosion•Migration•Twiddler’s syndrome•Muscle stimulation•Chronic pain

•Venous thrombosis•Intracardiac thrombus•Lead Endocarditis•Tricuspid valve entanglement•TR

•Displacement•Perforation•Diaphragmatic pacing

Lead EndocarditisLead Endocarditis

Venous ObstructionVenous Obstruction

<obstruction

Pacemaker SyndromePacemaker Syndrome

Dizziness

Presyncope

Chest tightness

Shortness of breath

Neck pulsations

Apprehension/malaise

Fatigue

PMTPMT

Conclusions IConclusions I Long rhythm strips with markers and IEGM’s

may needed for correct diagnosis 12 lead paced ECG is very valuable Know the timing cycles Do not attribute patient symptoms to age,sex

or underlying heart disease Do not leave the pacemaker at factory

settings, since every patient has different necessities.

Conclusions IIConclusions II

Make every effort to prolong battery life The other purpose of pacing is optimization of

quality of life Optimal AV delay can not be predicted Test the retrograde VA conduction Keep the records carefully Be obsessive in pacemaker dependent

patient