Pacemaker troubleshooting single chamber pacemakers
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Pacemaker troubleshooting-single chamber pacemakers. Reasons for evaluation. Patient symptomatic Palpitation Syncope presyncope Pacemaker malfunction suspected ECG Telemetry Ambulatory ECG Routine pacemaker follow up. Patient details. Indication for pacing Implant operative note

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Pacemaker troubleshooting single chamber pacemakers

Pacemaker troubleshooting-single chamber pacemakers


Reasons for evaluation

Reasons for evaluation

  • Patient symptomatic

    • Palpitation

    • Syncope

    • presyncope

  • Pacemaker malfunction suspected

    • ECG

    • Telemetry

    • Ambulatory ECG

  • Routine pacemaker follow up


Patient details

Patient details

  • Indication for pacing

  • Implant operative note

  • Diagnosis

  • Medication –can alter pacing tresholds

  • DC ,MRI,electrocautery

  • Trauma,electrical current exposure

  • Concurrent medical problems-CRF,hyperkalemia

  • Prior ECG,CXR


Pacemaker troubleshooting single chamber pacemakers

Pacemaker system

  • manufacturer

  • Model

  • current programming

  • date of implant

  • special features

  • Sensing and pacing tresholds

  • impedance


Pacemaker troubleshooting single chamber pacemakers

Lead system

  • manufacturer

  • model

  • polarity

  • Fixation

  • insulation and date


Causes of pacemaker malfunction

Causes of pacemaker malfunction

  • Pacing stimuli present with failure to capture

  • Pacing stimuli present with failure to sense

  • Pacing stimuli absent

    • Oversensing

    • No output

  • Pseudomalfunction


Failure to capture

Failure to capture

  • No evidence of depolarization after pacing artifact

Loss of capture


Early post device implantation

Early post device implantation

  • CXR abnormal

    • Lead dislodgement

      • Downward migration of PG

      • Failure to secure anchoring sleeves properly

      • Too little or too much slack

    • Lead perforation

  • Elevated impedance

    • Loose set screw

    • failure to seat lead pin properly in header

  • Normal CXR,normal impedance

    • Micro lead dislodgement

    • Inflammatory response


Late post device implantation

Late post device implantation

  • Battery depletion

  • Twiddler s syndrome

  • Abnormal myocardium

  • Insulation failure

  • Conductor failure

    • Mechanical stress on lead

      • Anchoring sleeve

      • Interaction with generator in pocket

      • b/w clavicle and first rib


Pacemaker troubleshooting single chamber pacemakers

  • Increase the energy in the output pulse

    • Run a capture threshold test

    • Adjust the output parameters, if necessary

      • Pulse amplitude (V)

      • Pulse width or duration (ms)

    • It is generally more efficient to increase the pulse amplitude

  • Investigate possible lead problems

  • Reprogram device polarity


Undersensing

Undersensing

  • An intrinsic depolarization that is present, yet not seen or sensed by the pacemaker

P-wavenot sensed

Atrial Undersensing


Pacemaker troubleshooting single chamber pacemakers

  • Undersensing occurs when the pacemaker does not detect intrinsic activity that really is there

  • Undersensing causes the pacemaker to pace more than it should


Undersensing may be caused by

Undersensing May Be Caused By:

  • Inappropriately programmed sensitivity

  • Lead dislodgment

  • Lead failure:

    • Insulation break; conductor fracture

  • Lead maturation

  • Change in the native signal

  • Functional

    • Magnet

    • Noise reversion


Pacemaker troubleshooting single chamber pacemakers

  • Adjust the sensitivity setting

    • Run a sensing threshold test

    • Measure the intrinsic signals

    • Adjust the sensitivity appropriately

      • To increase sensitivity, decrease the mV setting

    • Make all changes to sensitivity settings in small steps since large changes may only introduce new sensing problems


Oversensing

Oversensing

  • The sensing of an inappropriate signal

    • Can be physiologic or nonphysiologic

...Though no activity is present

Marker channel shows intrinsic activity...

Ventricular Oversensing


Pacemaker troubleshooting single chamber pacemakers

  • Oversensing occurs when the pacemaker inappropriately “thinks” that it sees intrinsic activity that is not there

  • Oversensing causes the pacemaker to inhibit the pacing output pulse, even though the device should be pacing


Pacemaker troubleshooting single chamber pacemakers

  • Myopotentials

    • Pectoralis,rectusabdominis,diaphragm

    • Bipolar leads are less susceptible

  • Oversensing of normal intracardiac signals

    • Reduce sensitivity of affected lead to eliminate oversensing

  • EMI

  • Provocative maneuvers may be needed if intermittent symptoms

  • Magnet eliminates pauses-oversensing


Pacemaker troubleshooting single chamber pacemakers

  • Reprogram the sensitivity

    • Conduct a sensing threshold test

    • Adjust the sensitivity by making the device less sensitive (increase the mV setting)

    • Make only small changes

  • Extend the refractory period


No output

No Output

  • Pacemaker artifacts do not appear on the ECG; rate is less than the lower rate

Pacing output delivered; no evidence of pacing spike is seen


No output may be caused by

No Output May Be Caused By:

  • Poor connection at connector block

  • Lead failure

  • Battery depletion

  • Circuit failure


Pacemaker troubleshooting single chamber pacemakers

  • Steps to take for possible loss of output

    • Verify all lead connections

    • Check lead integrity

    • Evaluate battery status

    • Contact the device manufacturer

  • Loss of output may require the replacement of all or part of the pacing system


Pseudomalfunctions

Pseudomalfunctions

Pseudomalfunctions are defined as:

Unusual,UnexpectedECG findings that appearto result from pacemaker malfunction but that represent normal pacemaker function


Pacemaker troubleshooting single chamber pacemakers

  • Hysteresis

  • Magnet rate

  • rate responsive pacing

  • Noise reversion

  • Rate drop response

  • Sleep rate algorithm


Hysteresis

Hysteresis

  • Allows a lower rate between sensed events to occur; paced rate is higher

Hysteresis Rate 50 ppm

Lower Rate 70 ppm


Magnet operation

Magnet Operation

  • Magnet application causes asynchronous pacing at a designated “magnet” rate


Pacemaker troubleshooting single chamber pacemakers

  • Threshold Margin Test (TMT)

    • Three beats at 100 bpm, followed by a magnet rate of 85

    • Third beat has an automatic pulse width decrement of 25%

    • Elective replacement indicators-change the rate from 85 to 65

  • Extended TMT.

    • TMT is performed at 100 ppm

    • Pulse width reduced by 25% on 3rd , 50% on 5th , and 75% on 7th


  • Rate responsive pacing

    Rate Responsive Pacing

    • An accelerating or decelerating rate may be perceived as anomalous pacemaker behavior

    VVIR / 60 / 120


    Electrical reset and battery depletion

    Electrical Reset and Battery Depletion

    • Reset may occur due to exposure to EMI

      electrocautery, defibrillation, causing reversion to a “back-up” mode

      • Rate and mode changes will occur

      • Device can usually be reprogrammed to former parameters

    • Elective replacement indicators (ERI) can resemble back-up mode

      • Interrogating device will indicate ERI (“Replace Pacer”)


    A change in pacing modes may be caused by

    A Change in Pacing Modes May Be Caused By:

    • Battery depletion indicators (ERI/EOL)

    • Electrical reset

    • Mode switching

    • Noise reversion


    Noise reversion

    Noise Reversion

    • Sensing occurring during atrial or ventricular refractory periods will restart the refractory period. Continuous refractory sensing is called noise reversion and will:

      • Cause pacing to occur at the sensor-indicated rate for rate-responsive modes

      • Cause pacing to occur at the lower rate for non- rate-responsive modes


    Noise reversion1

    Noise reversion

    VT in a patient with VVI-pacing occurs at lower rate due to noise reversion


    Rate drop response

    Rate drop response

    Delivers pacing at high rate when episodic drop in rate occurs


    Muscle stimulation may be caused by

    Muscle Stimulation May Be Caused By:

    • Inappropriate electrode placement near diaphragm or nerve plexus

    • Break in lead insulation

    • Unipolar pacing


    Flouro diagnosis

    Flouro diagnosis


    Pacemaker troubleshooting single chamber pacemakers

    1.ECG shows

    A.Failure to sense

    B.Failure to capture

    C.Hysteresis

    D.Oversensing


    Pacemaker troubleshooting single chamber pacemakers

    2.ECG shows

    A.Failure to sense

    B.Failure to capture

    C.Hysteresis

    D.Oversensing


    Pacemaker troubleshooting single chamber pacemakers

    3.ECG shows

    A.Failure to sense

    B.Failure to capture

    C.Hysteresis

    D.Oversensing


    Pacemaker troubleshooting single chamber pacemakers

    • 4.ECG demonstrates

      a.Failure to sense

      b.Failure to capture

      c.Functional non capture

      d.fusion


    Pacemaker troubleshooting single chamber pacemakers

    5

    ECG shows A.Failureto sense

    B.Failureto capture

    C.Hysteresis

    D.Functionalnon capture


    Pacemaker troubleshooting single chamber pacemakers

    6

    ECG shows

    A.Functional non capture

    B.Failure to capture

    C.Hysteresis

    D.Oversensing


    Pacemaker troubleshooting single chamber pacemakers

    7.possibilities are

    • A.VVI in VOO mode

    • B.magnet kept

    • C.persistent ventricular undersensing

    • D.Noise reversion


    Pacemaker troubleshooting single chamber pacemakers

    • 8.make and break potentials usually cause

    • A.undersensing

    • B.oversensing

    • C.functional non capture

    • D.failure to capture


    Pacemaker troubleshooting single chamber pacemakers

    • 9.elevated pacing threshold and elevated impedance can be caused by

    • A.lead fracture

    • B.loose set screw

    • C.insulation failure

    • D.battery depletion


    Pacemaker troubleshooting single chamber pacemakers

    • 10.elevated threshold with decreased impedance caused by

    • A.lead fracture

    • B.loose set screw

    • C.insulation failure

    • D.battery depletion


    Pacemaker troubleshooting single chamber pacemakers

    11.What are appropriate in this patient

    A.sensitivity setting to be adjusted

    B.lower the programmed rate

    C.introduce hysteresis

    D.check capture treshold


    Pacemaker troubleshooting single chamber pacemakers

    12.What is the next step in this patient

    • A.adjust sensitivity-increase mV setting

    • B.adjust sensitivity-decrease mV setting

    • C.pacingtreshold test-adjust output parameters

    • D.activate hysteresis


    Pacemaker troubleshooting single chamber pacemakers

    13.What is appropriate in this patient

    • A.adjust sensitivity-increase mV setting

    • B.adjust sensitivity-decrease mV setting

    • C.pacingtreshold test-adjust output parameters

    • D.activate hysteresis


    Pacemaker troubleshooting single chamber pacemakers

    14.What is appropriate in this patient

    • A.adjust sensitivity-increase mV setting

    • B.adjust sensitivity-decrease mV setting

    • C.pacingtreshold test-adjust output parameters

    • D.activate hysteresis


    Pacemaker troubleshooting single chamber pacemakers

    15.What is appropriate in this patient

    • A.adjust sensitivity-increase mV setting

    • B.adjust sensitivity-decrease mV setting

    • C.pacingtreshold test-adjust output parameters

    • D.activate hysteresis


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