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Pacemakers and Implantable Cardioverter Defibrillators

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    1. Pacemakers and Implantable Cardioverter Defibrillators

    3. Temporary Cardiac Pacing Transvenous Transcutaneous Epicardial Transesophageal

    4. Indications for Temporary Pacing Acute myocardial infarction with: CHB, Mobitz type 2 AV block, medically refractory symptomatic bradycardia, alternating BBB, new bifascicular block, new BBB with anterior MI In absence of acute MI : SSS, CHB, Mobitz type 2 AV block Treatment of tachyarrhythmias : VT

    5. Temporary Transvenous Pacing Unipolar Electrograms

    6. Paced QRS Morphology

    7. Permanent Pacing

    8. The Pacemaker System Patient

    9. Pacemaker Implantation Epicardial Transvenous : Generator implanted anterior to pectoral muscle Atrial/Ventricular leads via subclavian or cephalic vein Sensing and pacing threshold Chest X-ray for pneumothorax, lead position

    12. Acute Complications of Pacemaker Implantation Venous access Pneumothorax, hemothorax Air embolism Perforation of central vein Inadvertent arterial entry Lead placement Brady tachyarrhythmia Perforation of heart, vein Damage to heart valve Generator Pocket hematoma Improper or inadequate connection of lead

    13. Delayed Complications of Pacemaker Therapy Lead-related Thrombosis/embolization SVC obstruction Lead dislodgement Infection Lead failure Perforation, pericarditis Generator-related Pain Erosion, infection Migration Damage from radiation, electric shock Patient-related Twiddler syndrome

    14. Codes Describing Pacemaker Modes

    15. DDD

    16. Indications for Pacing for AV Block

    17. Indications for Pacing for Sinus Node Dysfunction

    18. 18 Mode Selection Considerations Status of Atrial Rhythm - Intrinsic vs. Paced - Presence of Atrial Tachyarrhythmias: Acute/Chronic Status of AV Conduction Normal -Slowed-Blocked Presence of Chronotropic Incompetence

    19. Choice of Pacing Mode

    20. Rate Responsive Pacing Goal: To provide an increased heart rate for the chronotropic incompetent patient The Pacemaker: Allows programming of a minimum rate and a maximum rate Is allowed to pace (in response to sensor input) at any rate in-between this min and max rate

    21. Todays Sensors Vibration non-physiologic Acceleration non-physiologic Minute Ventilation physiologic Temperature physiologic

    22. Case #1 72 year old male with chronic atrial fibrillation of greater than 10 years duration is admitted following a syncopal episode. A 2D echo shows LVEF 60%. Telemetry reveals atrial fibrillation with slow ventricular response and pauses of 4 to 6 seconds associated with lightheadedness. How would you proceed?

    23. Case #1 72 year old male with chronic atrial fibrillation of greater than 10 years duration is admitted following a syncopal episode. A 2D echo shows markedly dilated left atrium and LVEF 60%. Telemetry reveals atrial fibrillation with slow ventricular response and pauses of 4 to 6 seconds associated with near syncope. How would you proceed? Answer: Implant a ventricular rate responsive pacemaker

    24. Pacemaker Follow-up GOAL OF FOLLOW-UP Verify appropriate pacemaker operation Optimize pacemaker functions Document findings, changes and final settings in order to provide appropriate patient management

    25. Pacemaker Magnet Application

    26. Pacemaker Troubleshooting Failure to capture high threshold, lead dislodgement, conductor coil fracture Failure to pace ( failure to output ) oversensing, circuit interruption, battery depletion Failure to sense undersensing, oversensing

    27. Intermittent Loss of Ventricular Capture

    28. Pacemaker Syndrome Fatigue, dizziness, hypotension Caused by pacing the ventricle asynchronously, resulting in AV dissociation or VA conduction Mechanism: atrial contraction against a closed AV valve and release of atrial natriuretic peptide Worsened by increasing the ventricular pacing rate, relieved by lowering the pacing rate or upgrading to dual chamber system Therapy with fludrocortisone/volume expansion NOT helpful

    29. Sources of Electromagnetic Interference Medical MRI Lithotripsy Electrocautery/cryosurgery External defibrillators Therapeutic radiation Nonmedical Arc welding equipment Automobile engines Radar Transmitters

    30. Expanded Indications for Pacing Cardiac resynchronization therapy Hypertrophic cardiomyopathy Neurocardiogenic syncope? Long QT syndrome

    31. Biventricular Pacing

    32. Normal Conduction Is Important Normal conduction allows for prompt and synchronous activation of the atria and ventricles Results in a brief P wave, PR interval and a narrow QRS

    33. Heart Failure Delayed Ventricular Activation

    34. Heart Failure Bifocal Ventricular Pacing

    36. Bi-Ventricular Pacing

    39. Baseline ECG

    40. Bi-V Pace

    41. Implantable Cardioverter Defibrillator (ICD)

    42. ICD Implantation Secondary prevention: Prevention of SCD in patients with prior VF or sustained VT. Primary prevention: Prevention of SCD in individuals without a h/o VF or sustained VT.

    43. Indications For ICD VF/sustained unstable VT not in the setting of a completely reversible cause. LVEF = 35%, CHF NYHA class II, III. Ischemic dilated cardiomyopathy, LVEF = 40%, NSVT and inducible sustained VT. Syncope, LV dysfunction, inducible sustained VT. High risk patients with: hypertrophic cardiomyopathy, LQT syndrome, RV dysplasia, Brugada syndrome

    45. ACC/AHA/HRS 2008 Guidelines: Systolic Heart Failure - Cardiac Resynchronization Therapy (CRT) Recommendations LVEF = 35% QRS = 120 msec NYHA functional Class III or ambulatory Class IV Optimal medical therapy

    46. Typical Case 58 year old male, CAD, prior MI, EF 28%, CHF, NYHA class II, Medications: Lasix 80 BID, Enalapril 20 BID, Aldactone 25 qd, Coreg 25 BID, no syncope or VT, ECG: Sinus rhythm, old anteroseptal MI, QRS 92 msec Question Based on available trial data, you would suggest: A. Treating medically without device implantation B. Implanting an ICD C. Implanting an ICD with biventricular pacing capabilities (3 leads)

    47. Typical Case Q: 60 year old female presents with a 1 year h/o non ischemic dilated cardiomyopathy, CHF NYHA class III despite maximum medical therapy, LVEF 20% and LBBB with QRS 170 msec. What device is indicated? A: Bi-Ventricular ICD

    48. 1 Prevention of Sudden Cardiac Death: Clinical Device Algorithm If CAD: (ACE Inhibitors, Beta Blockers)

    49. 1 Prevention: Clinical Device Algorithm If Non Ischemic Dilated Cardiomyopathy: