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Muhammad Diah

Instalasi Kateterisasi Jantung

Cardiology Sub Div, Depart Internal Medicene

RSUD Zainoel Abidin, Banda Aceh

Cardiology Sub Div, Depart Internal Medicene

RSHM Palembang

1

ECG - Pacemakers

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2013-12-7. M.Diah2

*First described in 1952

*Introduced into clinical practice in 1960

*First endocardial defibrillators in 1980

*1991 in USA 1 million people had permanent

pacemakers

*Now

- Approximately 3 million with pacemakers

- Approximately 1 million with ICD device

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2013-12-7. M.Diah3

*Indications

*Basics, Pacemaker Components and Code

*ECG in Pacemaker

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*Provides electrical stimuli to cause cardiac

contraction when intrinsic cardiac activity is

inappropriately slow or absent*Sense intrinsic cardiac electric potentials

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* Stimulate cardiac depolarization

* Sense intrinsic cardiac function

* Respond to increased metabolic demand by

providing rate responsive pacing

* Provide diagnostic information stored by the

pacemaker

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Clinical Indication

for Pacer1. Symptomatic bradycardia

2. Symptomatic heart block

- 2nddegree heart block

- 3rdor complete heart block

- Bifasicular or transfasicular bundlebranch blocks.

3. Prophylaxis

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*

*Pulse Generator

*Electronic Circuitry

*Lead System

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Lead

Pace

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*Subcutaneous or submuscular

*Lithium battery*4-10 years lifespan

*long life and gradual decrease in power

sudden pulse generator failure is anunlikely cause of pacemaker malfunction

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PPM

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*Sensing circuit*Timing circuit

*Output circuit

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Bipolar

*Lead has both negative,

(Cathode) distal andpositive, (Anode) proximalelectrodes

*Separated by 1 cm

*Larger diameter: moreprone to fracture

*Compatible with ICD

Unipolar

* Negative (Cathode)

electrode in contactwith heart

* Positive (Anode)electrode: metal casingof pulse generator

* Prone to oversensing

* Not compatible withICD

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*current travels only a

short distance

between electrodes

*small pacing spike:

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*current travels a

longer distancebetween electrodes

*larger pacing spike:

>20mm

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-

Anode

Cathode

+

-

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I

Chamber

Paced

II

Chamber

Sensed

III

Response

to Sensing

IV

Programmable

Functions/RateModulation

V

Antitachy

Function(s)

V: Ventricle V: Ventricle T: Triggered

P: Simple

programmable P: Pace

A: Atrium A: Atrium I: InhibitedM: Multi-

programmableS: 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

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*1stletter chamber paced

*2

nd

letter

chamber sensed*3rdletter Response to chamber sensed

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*AAT

*Paces atria

*Senses atria

*Triggers generator to fire if atria sensed

*VVI

Ventricular Pacing : Ventricular sensing; intrinsicQRS Inhibits pacer discharge

*VVIR

As above + has biosensor to provide Rate-responsiveness

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*DDDPaces + Senses both atrium + ventricle,intrinsic cardiac activity inhibits pacer d/c, noactivity: trigger d/c

*DDDR

As above but adds rate responsiveness toallow for exercise

*VVI*Paces ventricle

*Senses ventricle

*Inhibited by a sensed ventricular event

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When the need for oxygenated blood increases,

the pacemaker ensures that the heart rate

increases to provide additional cardiac outputAdjusting Heart Rate to Activity

Normal Heart Rate

Rate Responsive Pacing

Fixed-Rate Pacing

Daily Activities

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* Wallet card: 5

letter code

* CXR: code visible

* Single lead in

ventricle: VVI* Separate leads

DDD or DVI

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*VVI - lead lies in

right ventricle*Independent of atrial

activity

*Use in AV conductiondisease

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VVI / 60

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*Typically in pts withnonfibrillating atria and

intact AV conduction*Native P, paced P, native

QRS, paced QRS

*ECG may be interpreted

as malfunction whennone is present

*May have fusion beats

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Rate = 60 bpm / 1000 ms

A-A = 1000 ms

APVP

APVP

V-AAV V-AAV

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Atrial Pace, Ventricular Pace (AP/VP)

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Atrial Spike Ventricular Spike*

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Rate = 60 ppm / 1000 ms

A-A = 1000 ms

APVS

APVS

V-AAV V-AAV

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Atrial Pace, Ventricular Sense (AP/VS)

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ASVP

ASVP

Rate (sinus driven) = 70 bpm / 857 ms

A-A = 857 ms

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Atrial Sense, Ventricular Pace (AS/ VP)

V-AAV AV V-A

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Rate (sinus driven) = 70 bpm / 857 ms

Spontaneous conduction at 150 ms

A-A = 857 ms

ASVS

ASVS

V-AAVAV

V-A

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Atrial Sense, Ventricular Sense (AS/VS)

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*EKG abnormalities due to

*Failure to output

*Failure to capture

*Sensing abnormalities

*Operative failures

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*Definition

*No pacing spike present despite indication to

pace

*Etiology*Battery failure, lead fracture, break in lead

insulation, oversensing, poor lead connection,

cross-talk

*Atrial output is sensed by ventricular lead

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*Definition

*Pacing spike is not followed by either an atrial or

ventricular complex

*Etiology*Lead fracture or dislodgement, break in lead

insulation, elevated pacing threshold, MI at lead

tip, drugs, metabolic abnormalities, cardiac

perforation, poor lead connection

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*Oversensing

*Senses noncardiac electrical activity and is inhibited fromcorrectly pacing

*Etiology

*Muscular activity (diaphragm or pecs), EMI, cell phoneheld within 10cm of pulse generator

*Undersensing

*Incorrectly misses intrinsic depolarization and paces

*Etiology

*Poor lead positioning, lead dislodgement, magnetapplication, low battery states, MI

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Due to pacemaker placement

*Pneumothorax

*Pericarditis

*Perforated atrium or ventricle

*Dislodgement of leads

*Infection or erosion of pacemaker pocket*Infective endocarditis (rare)

*Venous thrombosis

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Pacemaker syndrome

*Patient feels worse after pacemaker placement

*Presents with progressive worsening of CHF symptoms

*Due to loss of atrioventricular synchrony, pathway now

reversed and ventricular origin of beat

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*Can interfere with function of pacemaker or

ICD*Device misinterprets the EMI causing

*Rate alteration

*Sensing abnormalities

*Asynchronous pacing

*Noise reversion

*Reprogramming

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Examples

*Metal detectors

*Cell phones

*High voltage power lines

*Some home appliances (microwave)

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*Intensity of electromagnetic field decreases inversely

with the square of the distance from the source*Newer pacemakers and ICDs are being built with

increased internal shielding

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*CC: Chills, rigors

*HPI:

*65 yom c/o fevers, chills, rigors x 1 day.Positive n/v and anorexia. Pt states hehad recent pacemaker insertion 4 days

ago for an arrhythmia.

*PMH:

*HTN

*Arrythmia*Hypercholesterolemia

*PSHx:

*As stated above

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*

*Physical exam

*Temp 101.2, HR 110, BP 90/55

*EKG

*Diagnosis?

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*

*Pocket Infection

*Pacemaker insertion is a surgical procedure

*1% risk for bacteremia*2% risk for pocket infection

*Usually occurs within 7 days of pacemakerinsertion

*May have tenderness and redness overpacemaker site

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*

*CC: SOB

*HPI:

*65 yom states he had onset of shortnessof breath and left sided pleuritic chestpain. Pt states he awoke with pain anddifficulty breathing. Had pacemaker

placed yesterday.*PMHx:

*HTN, Diabetes, Hypercholesterolemia,Arrythmia, CAD

*PSHx:*Pacemaker, left knee surgery, b/lcataract

*

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*

*Physical Exam*BP 146/85, HR 80s, RR 30s, O2 Sat 88%

*Lungs

*Decreased breath sounds on left

*EKG

*Diagnosis?

*

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*

*Pneumothorax

*Occurs during cannulation of central veins

*Incidence

*Cardiologist dependent

*Treatment

*Small or asymptomatic observation

*Large or symptomatic Chest tube

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*

*CC: Cardiac arrest

*HPI: 59 yom found on couch. Wife states they

were watching TV when patient let out a moanand then became unconscious. She states, hehas a bad heart and had somethingput in afew years ago.

*PMHx: unknown

*Meds: bottles in bathroom

*

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*

*Physical Exam*Airway patent, no visible chest rise, no

pulses

*Generally: cool, clammy, diaphoretic

*EKG:

*Diagnosis?

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*

*Cardiac Arrest with ICD (V-fib)

*2% annual incidence with ICD

*Etiology

* ICD delivered predetermined shocks for

identified event and patient failed to respond

* ICD failed to recognize event and failed to shock

appropriately

*Failure to sense, lead fracture, EMI, inadvertent ICDdeactivation

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*

*Cardiac Arrest with ICD

*Treat using ACLS protocols

*Secure airway

*CPR

*Defibrillate/shock as warranted

*Keep sternal pad 10 cm away from pulse generator

*Meds