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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

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”

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 bradycardia Intermittent – faintness / syncope Persistent – SOB / muscle fatigue / exhaustion
  • Associated atrial tachyarrhythmias / AV Block Intermittent – palpitations / faintness / syncope Persistent – SOB / muscle fatigue / exhaustion
  • Associated clinical syndromes Embolic Heart 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

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

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

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
SA Slow Sinus Rate

AV Block



Paced Patients: Predominant ECG Indication

BPEG / HRUK National Database 2003 - 4

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

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

1% A Lead only

55% A + V Leads (Dual Chamber)

44% V Lead only (mostly in AF)

V lead normally @ RV apex


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

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

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.’