Bradyarrhythmia s pacemaker s complex devices
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Bradyarrhythmia’s, Pacemaker’s & Complex Devices. Dr Chris McAloon Medical Student Teaching. Overview. Interpreting Bradyarrhythmia’s Different types of Bradyarrhythmia’s Pacemakers Complex Devices. First Rule. “ Always look at the patient”. Conducting system. Heart Blocks. NSR

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Bradyarrhythmia’s, Pacemaker’s & Complex Devices

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Bradyarrhythmia s pacemaker s complex devices

Bradyarrhythmia’s, Pacemaker’s & Complex Devices

Dr Chris McAloon

Medical Student Teaching



  • Interpreting Bradyarrhythmia’s

  • Different types of Bradyarrhythmia’s

  • Pacemakers

  • Complex Devices

First rule

First Rule

“ Always look at the patient”

Conducting system

Conducting system

Heart blocks

Heart Blocks

  • NSR

  • Sinus brady

  • SSS

  • Sinoatrial block

  • Sinus arrest

Heart blocks1

Heart Blocks

  • 1st degree

  • 2nd degree

    • Mobitz Type 1

    • Mobitz Type 2

    • 2:1, 3:1 AVB

  • 3rd degree

  • Fascicular block - LAD, RAD, TFB


  • AF, Flutter

Reversible causes of slow heart rate

Reversible Causes of Slow Heart Rate

  • Drug therapy

  • Acute Myocardial Infarction

  • Hypothermia

  • Hypothyroidism

  • Athletic Heart

  • Vaso-vagal mechanisms

Complete av block

Complete AV Block

  • All patients with persistent or intermittent complete AV block should be paced unless there is a reversible cause Irrespective of symptoms

  • Reversible causes include recent inferior MI,

  • hypothyroidism and drugs

  • This includes patients with congenital CHB

  • If you are not going to pace, you really need to be able to justify that decision

Sinus node dysfunction

Sinus Node Dysfunction

  • Inappropriate bradycardiaIntermittent – faintness / syncope Persistent – SOB / muscle fatigue / exhaustion

  • Associated atrial tachyarrhythmias / AV BlockIntermittent – palpitations / faintness / syncope Persistent – SOB / muscle fatigue / exhaustion

  • Associated clinical syndromesEmbolicHeart Failure

The als approach

The ‘ALS’ Approach

  • Is there electrical activity?

  • What is the ventricular (QRS) rate?

  • Is the QRS rhythm regular or irregular?

  • Is the QRS complex width normal or prolonged?

  • Is there atrial activity present?

  • Is the atrial activity related to ventricular activity, if so how?

The heart block system

The Heart Block System

  • Are the P waves associated with the QRS complex at all?

    No = This is 3rd Degree Heart Block

    Yes= Move to Question 2

Third degree complete heart block

Third Degree/ Complete Heart Block

The heart block system1

The Heart Block System

  • Is there one P wave to one QRS, with a prolonged PR interval that is not progressing (in length)?

    Yes= This is 1st Degree Heart block

    No = Go to question 3

First degree heart block

First Degree Heart Block

The heart block system2

The Heart Block System

3.Is there progression in PR interval duration until there is a non-conducted P wave?

Yes= This is Wenckebach

No = Go to question 4

Mobitz type 1 wenckebach

Mobitz Type 1/ Wenckebach

The heart block system3

The Heart Block System

  • Therefore it must be Mobitz type 2

  • Mobitz type 2 difficult to explain

  • P waves conducted normal PR interval

  • There are P waves that are not conducted

  • Not always a specific block

    • 2:1

    • 3:1

    • 4:3

  • Mobitz type 2

    Mobitz Type 2

    Mobitz 2 3 1 block

    Mobitz 2 – 3:1 Block

    Bradyarrhythmia s pacemaker s complex devices

    SA Slow Sinus Rate

    AV Block



    Pacemaker s


    Pacing indications

    Pacing Indications

    Bradyarrhythmia s pacemaker s complex devices

    Paced Patients: Predominant ECG Indication

    BPEG / HRUK National Database 2003 - 4

    Bradyarrhythmia s pacemaker s complex devices

    Paced Patients: Predominant Presenting Symptom

    BPEG / HRUK National Database 2003-4

    Pacing indications1

    Pacing Indications

    • AV Block

      • Complete Heart Block

      • Second degree AV block (High block or symptoms)

      • Reversible: Inferior MI, Hypothyroidism

    • Sinus Node Disease

      • Chronotropic Incompetence

      • If resting HR in day time <30

    • Atrial Fibrillation

      • Bradycardia

      • Bradycardia in presence drugs for uncontrolled Tachycardia

    International codes pacemaker

    International Codes Pacemaker

    First Letter = Chamber(s) being PACED (A,V,D)

    Second Letter = Chamber(s) being SENSED

    Third Letter= How the device RESPONDS to SENSED Event (Inhibits, Triggers, Dual (I+T))

    Fourth Letter = Added feature e.g R = Rate Response

    Pacemaker basic s

    Pacemaker Basic’s

    A unipolar system

    A Unipolar System

    A bipolar system

    A Bipolar System

    What is the ppm

    What is the PPM?

    What is the ppm1

    What is the PPM?

    What is the ppm2

    What is the PPM?

    What is the ppm3

    What is the PPM?

    Electrodes fixation mechanism

    Electrodes -- Fixation Mechanism

    • Passive Fixation Mechanism – Endocardial

      • Tined

      • Finned

      • Canted/curved

    Electrodes fixation mechanism1

    Electrodes – Fixation Mechanism

    • Active Fixation Mechanism – Endocardial

      • Fixed screw

      • Extendible/retractable

    Pacemaker prescription

    Pacemaker Prescription

    • Re-establish stable heart rate

    • Restore AV synchrony

    • Achieve chronotropic competence

    • Achieve normal physiological activation and timing

    • A lead if normal A function

    • V lead if actual / threatened AV HB

    • Rate modulation if slow

    Bradyarrhythmia s pacemaker s complex devices


    1% A Lead only

    55% A + V Leads (Dual Chamber)

    44% V Lead only (mostly in AF)

    V lead normally @ RV apex


    Complex devices

    Complex Devices

    Complex devices1

    Complex Devices

    What can be done

    What can be done?

    What can be done1

    What can be done?



    Heart failure and crt

    Heart Failure and CRT

    Heart failure common and disabling condition

    • Cardiac resynchronization therapy (CRT)

      • Applicable to ~1/3 of all symptomatic HF patients

      • Improvement in long term survival

    • NICE indications

      • NYHA III/IV, Optimal medical therapy

      • LVEF <35%

      • QRS > 120ms

    • However, 20-30% non responders to CRT

    Bradyarrhythmia s pacemaker s complex devices

    CARE-HF: CRT vs Medical Therapy - Primary End Point

    Cleland, J. et al. N Engl J Med 2005;352:1539-1549

    Bradyarrhythmia s pacemaker s complex devices

    NICE Guidance 95 & 120

    Global heroes 2012 10 mile run

    Global Heroes 2012: 10 mile run

    • Susan Filler was an avid runner

    • 2007 survived Cardiac Arrest

    • ARVD diagnosed & ICD implanted

    • Completed Boise & Canada Ironman

    • Patrick Grayson 21

    • Long QT diagnosed at 11

    • At 12 Cardiac Arrest & ICD implanted

    • Protection of ICD gave confidence to run

    • February 2012 ran 1st marathon

    • Erin Clark

    • 20 years ago SCA, diagnosed Long QT

    • BB 1st, then implanted ICD.

    • ICD gave confidence to be active as protection

    • 1 year ago started running

    What patients say about icd

    What patients say about ICD

    • When I die will this keep shocking me? In my coffin?

    • One day I want to join my wife – how can I do that with an ICD?

    • Can I be comfortable at the end of my life?

    • Will Deactivation hurt? Do I need surgery?

    • Will I die immediately after the ICD is deactivated?

    • I feel like the bionic man – can I die with this?

    Esc guidance 2010


    • ‘It seems clear at this point that this device is in your best interest, but you should know at some point if you become very ill from your heart disease or another process you developing the future, the burden of this device may outweigh its benefit. While that point is hopefully a long way off, you should know that turning off your defibrillator is an option.’

    • ‘Now that we’ve established that you would not want resuscitation in the event your heart was to go into an abnormal pattern of beating, we should reconsider the role of yourdevice. In many ways it is also a form of resuscitation. Tell me your understanding of the device and let’s talk about how it fits into the larger goals for your medical care at this point.’

    • ‘Clinicians may be concerned that withdrawing life-sustaining treatments such as CIED (ICD) therapies amounts to assisted suicide or euthanasia. However, two factors differentiate withdrawal of an unwanted therapy from assisted suicide and euthanasia: the intent of the clinician, and the cause of death. First, in withdrawing an unwanted therapy, the clinician’s intent is not to hasten the patient’s death, but rather, to remove a treatment that is perceived by the patient as a burden.’

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