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Pacemaker for beginners KITA yosuke Iizuka Hospital Objectives Review basic pacemaker terminology and function Discuss diagnosis and management of pacemaker emergencies Historical Perspective Electrical cardiac pacing for the management of brady-arrhythmias was first described in 1952

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Pacemaker for beginners l.jpg

Pacemaker for beginners

KITA yosuke

Iizuka Hospital


Objectives l.jpg
Objectives

  • Review basic pacemaker terminology and function

  • Discuss diagnosis and management of pacemaker emergencies


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Historical Perspective

  • Electrical cardiac pacing for the management of brady-arrhythmias was first described in 1952

  • Permanent transvenous pacing devices were first introduced in the early 1960’s


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Pacemaker Components

  • Pulse Generator

  • Electronic Circuitry

  • Lead system


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Pulse Generator

  • Lithium-iodine cell is the current standard battery

  • Advantages:

    • Long life – 4 to 10 years

    • Output voltage decreases gradually with time making sudden battery failure unlikely


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Electronic Circuitry

  • Determines the function of the pacemaker itself

  • Utilizes a standard nomenclature for describing pacemakers



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Lead Systems

  • Endocardial leads which are inserted using a subclavian vein approach

  • Actively fixed to the endocardium using screws or tines

  • Unipolar or bipolar leads


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Electrocardiogram During Cardiac Pacing

  • Pacemaker has two main functions:

    • Sense intrinsic cardiac electrical activity

    • Electrically stimulate the heart

  • VVI- senses intrinsic cardiac activity in the ventricle and when a preset interval of time with no ventricular activity occurs it depolarizes the right ventricle causing ventricular contraction



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Electrocardiogram

  • Dual chamber pacer is more complicated because the pacer has the ability to both sense and pace either the atrium or the ventricle

  • Possible to have only atrial, only ventricular or both atrial and ventricular pacing

  • DDD pacer is a common example of this


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Atrial Spike

Ventricular Spike



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Magnet Placement

  • The EKG technician should perform a 12 lead cardiogram and then a rhythm strip with a magnet over the pacer

  • Often a very poorly understood concept by the non-cardiologist

  • Does not inactivate the pacer as is commonly believed

  • Activate a lead switch present in the pacemaker which converts the pacer to a asynchronous or fixed-rate pacing mode

  • Inhibits the sensing function of a pacemaker


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Class I Indications For Permanent Pacing

  • Third degree AV block associated with:

    • Symptomatic bradycardia

    • Symptomatic bradycardia secondary to drugs required for dysrhythmia management

    • Asystole > 3 seconds or escape rate < 40

    • After catheter ablation of the AV node

    • Post-op AV block not expected to resolve

    • Neuromuscular disease with AV block


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Indications

  • Symptomatic bradycardia from second degree AV block

  • Bifascicular or trifascicular block with intermittent third degree or type II second degree block

  • Sinus node dysfunction with symptomatic bradycardia

  • Recurrent syncope caused by carotid sinus stimulation


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Indications

  • Post myocardial infarction with any of:

    • Persistent second degree AV block with bilateral bundle branch block or third degree AV block

    • Transient second or third degree AV block and bundle branch block

    • Symptomatic, persistent second or third degree AV block


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Infections

  • Pacemaker insertion is a surgical procedure:

    • 1% risk for bacteremia

    • 2% risk for wound or pocket infection

  • Usually occur soon after pacer insertion

  • Presence of a foreign body complicates management


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Infection

  • Cellulitis or pocket infection:

    • Tenderness and redness over the pacemaker itself

    • Avoid performing a needle aspiration – damage the pacer

  • Bacteremia: Staphylococcus

    • aureus and Staphylococcus epi 60-70% of the time

    • Empiric antibiotics should include vancomycin pending culture


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Infection

  • Consult the pacemaker physician

  • Draw blood cultures

  • Give appropriate antibiotics

  • Frequently the pacer and lead system need to be removed


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Case 1

  • 67 year old male presents to the emergency room 12 hours after insertion of a pacemaker complaining of left sided chest pain and shortness of breath

  • PR96, RR 33, BP 125/85, Oxygen saturation 88% RA

  • CXR as shown


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Pneumothorax

  • Occurs during cannulation of the subclavian vien

  • Incidence - ?? Cardiologist dependent

  • Treatment:

    • Asymptomatic or small – observation

    • Symptomatic or large – tube thoracostomy

  • Notify the pacemaker physician


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Case 2

  • 72 year old male presents to the emergency room after a fall, tripped over a bath mat, no LOC

  • Shortened and rotated left leg

  • Past history – pacemaker, hypertension

  • Nurse does an routine pre-op CXR and EKG


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Septal Perforation

  • Usually identified at the time of pacer insertion but leads can displace after insertion

  • Can occur with transvenous pacer insertion

  • Keys diagnosis are a RBBB pattern on EKG and a pacer lead displaced to the apex of the heart on CXR


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Septal Perforation

  • Management:

    • Notify the pacer service

    • Pacer wire has to be removed but not emergently

    • Small VSD which heals spontaneously


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Conclusions

  • Pacemakers are becoming more common everyday

  • We need to understand basic pacing terminology and modes to treat patients effectively.

  • Most pacer malfunctions are due to failure to sense, failure to capture, over-sensing, or in-appropriate rate

  • Standard ACLS protocols apply to all unstable patients with pacemakers.


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