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Principles of Cardiac Pacing. Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery. Cardiac Conduction System. Cardiac Conduction System. Bundle of His. Right and Left Bundle Branches. Coronary Artery Disease

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principles of cardiac pacing
Principles of Cardiac Pacing

Seoul National University Hospital

Department of Thoracic & Cardiovascular Surgery

slide3

Cardiac Conduction System

Bundle of His

Right and Left

Bundle Branches

slide4

Coronary Artery Disease

  • Idiopathic Degeneration
  • Calcification
  • Endocarditis
  • Heart Surgery
  • RF Ablation

Factors Influencing Conduction System

choice of aai aair mode
Choice of AAI/AAIR Mode

A. Indications

1. Symptomatic sinus node dysfunction with adequate AV

conduction (AAI)

2. Hemodynamic enhancement through rate adjustment in

patients who have bradycardia and symptoms of impaired

cardiac output with adequate AV conduction (AAI)

3. 1 and 2, above, in the presence of chronotropic incompetence

and an anticipated high level of physical activity, normal AV

conduction, and little evidence for intrinsic or drug-induced

AV block (AAIR)

B. Contraindications

1. Preexisting AV conduction delay or block or if decremental

conduction is demonstrated at slow paced rates

2. Inadequate atrial pacing/sensing threshold

3. Inexcitable atrial tissue

choice of vvi vvir mode
Choice of VVI/VVIR Mode

A. Indications

1. Symptomatic bradyarrhythmia in the setting of no significant

atrial hemodynamic contribution to cardiac output (eg. AF, SVT)

(VVI)

2. No evidence of pacemaker syndrome (VVI)

3. Symptomatic bradycardia where pacing simplicity is a prime

concern (eg. Senility, terminal D.) (VVI)

4. 1 and 2, above, with the presence of chronotropic incompetence

and an anticipated high level of physical activity (VVIR)

B. Contraindications

1. Known pacemaker syndrome

2. Retrograde ventriculoatrial conduction with angina pectoris or

congestive heart failure

3. Congestive heart failure where atrial contribution to cardiac

output is important

choice of ddd dddr mode
Choice of DDD/DDDR Mode

A. Indications

1. Requirement for AV synchrony over a wide range of rates (DDD)

2. Complete heart block or sick sinus syndrome and stable atrial

rates (DDD)

3. When simultaneous control of atrial and ventricular rates can

be demonstrated to inhibit tachyarrhythmias directly or by

programming changes (DDD)

4. 1 through 3, above, in patients with chronotropic incompetence

and an anticipated moderate to high level of physical activity

and in whom there is a stable atrial rhythm (DDDR)

B. Contraindications

1. Frequent or persistent supraventricular tachyarrhythmias,

including atrial fibrillation and/or flutter

2. Inadequate atrial pacing/sensing threshold

3. Severe ischemic heart disease where angina is precipitated by

an increased rate

choice of ddi ddir mode
Choice of DDI/DDIR Mode

A. Indications

1. Patients who require dual-chamber pacing and who have

frequent but not constant supraventricular arrythmias; atrial

arrhythmias caused by competitive pacing are avoided because

the atrial output is inhibited by an atrial or ventricular event

(DDI)

2. 1, above, in patients with chronotropic incompetence

and an anticipated moderate to high level of physical activity

and in whom dual-chamber pacing is needed (DDIR)

B. Contraindications

1. Frequent or persistent supraventricular tachyarrhythmias,

including atrial fibrillation and/or flutter

2. Inadequate atrial pacing/sensing threshold

3. Severe ischemic heart disease where angina is precipitated by

an increased rate

slide10

Sick Sinus Syndrome

  • Sinus bradycardia
  • Sinus arrest
  • Sinoatrial exit block
  • Atrial fibrillation with a slow ventricular response
  • Tachy-brady syndrome
slide12

Sinus Arrest & Sinoatrial Exit Block

Sinus Arrest

SA Exit Block

slide13

Atrial Fibrillation with Slow

Ventricular Response

slide15

Second Degree A-V Block

  • Mobitz Type I (Wenckebach)
  • Mobitz Type II
slide18

NASPE / BPEG (NBG)

Pacemaker Code

slide19

The NASPE/BPEG Generic (NBG) Code

Position

I

II

III

IV

V

Category

Chamber(s)

Paced

Response

to Sensing

Programmability,

rate modulation

Antitachy-

arrhythmia

Function(s)

Chamber(s)

Sensed

Letters

Used

  • O-None
  • A-Atrium
  • V-Ventricle
  • D-Dual
    • (A+V)
  • O-None
  • A-Atrium
  • V-Ventricle
  • D-Dual
    • (A+V)
  • O-None
  • T-Triggered
  • I-Inhibited
  • D-Dual
    • (T+I)
  • O-None
  • P-Simple
    • Programmable
  • M-Multi-
    • Programmable
  • C-Communicating
  • R-Rate
    • modulation
  • O-None
  • P-Pacing
    • (antitachy-
    • arrhythmia)
  • S-Shock
  • D-Dual
    • (P+S)
  • S- Single
    • (A or V)

Manufac-

turer’s

Designation

Only

  • S- Single
    • (A or V)

I=Pacing II=Sensing III=Sensing

slide20

The NASPE/BPEG Generic (NBG) Code

Position

I

II

III

IV

V

Category

Chamber(s)

Paced

Response

to Sensing

Programmability,

rate modulation

Antitachy-

arrhythmia

Function(s)

Chamber(s)

Sensed

Letters

Used

  • O-None
  • A-Atrium
  • V-Ventricle
  • D-Dual
    • (A+V)
  • O-None
  • T-Triggered
  • I-Inhibited
  • D-Dual
    • (T+I)
  • O-None
  • P-Simple
    • Programmable
  • M-Multi-
    • Programmable
  • C-Communicating
  • R-Rate
    • modulation
  • O-None
  • P-Pacing
    • (antitachy-
    • arrhythmia)
  • S-Shock
  • D-Dual
    • (P+S)
  • O-None
  • A-Atrium
  • V-Ventricle
  • D-Dual
    • (A+V)
  • S- Single
    • (A or V)

Manufac-

turer’s

Designation

Only

  • S- Single
    • (A or V)
slide21

The NASPE/BPEG Generic (NBG) Code

Position

I

II

III

IV

V

Category

Chamber(s)

Paced

Response

to Sensing

Programmability,

rate modulation

Antitachy-

arrhythmia

Function(s)

Chamber(s)

Sensed

Letters

Used

  • O-None
  • A-Atrium
  • V-Ventricle
  • D-Dual
    • (A+V)
  • O-None
  • T-Triggered
  • I-Inhibited
  • D-Dual
    • (T+I)
  • O-None
  • P-Simple
    • Programmable
  • M-Multi-
    • Programmable
  • C-Communicating
  • R-Rate
    • modulation
  • O-None
  • P-Pacing
    • (antitachy-
    • arrhythmia)
  • S-Shock
  • D-Dual
    • (P+S)
  • O-None
  • A-Atrium
  • V-Ventricle
  • D-Dual
    • (A+V)
  • S- Single
    • (A or V)

Manufac-

turer’s

Designation

Only

  • S- Single
    • (A or V)
slide22

The NASPE/BPEG Generic (NBG) Code

Position

I

II

III

IV

V

Category

Chamber(s)

Paced

Response

to Sensing

Programmability,

rate modulation

Antitachy-

arrhythmia

Function(s)

Chamber(s)

Sensed

Letters

Used

  • O-None
  • A-Atrium
  • V-Ventricle
  • D-Dual
    • (A+V)
  • O-None
  • T-Triggered
  • I-Inhibited
  • D-Dual
    • (T+I)
  • O-None
  • P-Simple
    • Programmable
  • M-Multi-
    • Programmable
  • C-Communicating
  • R-Rate
    • modulation
  • O-None
  • P-Pacing
    • (antitachy-
    • arrhythmia)
  • S-Shock
  • D-Dual
    • (P+S)
  • O-None
  • A-Atrium
  • V-Ventricle
  • D-Dual
    • (A+V)
  • S- Single
    • (A or V)

Manufac-

turer’s

Designation

Only

  • S- Single
    • (A or V)
slide23

The NASPE/BPEG Generic (NBG) Code

Position

I

II

III

IV

V

Category

Chamber(s)

Paced

Response

to Sensing

Programmability,

rate modulation

Antitachy-

arrhythmia

Function(s)

Chamber(s)

Sensed

Letters

Used

  • O-None
  • A-Atrium
  • V-Ventricle
  • D-Dual
    • (A+V)
  • O-None
  • T-Triggered
  • I-Inhibited
  • D-Dual
    • (T+I)
  • O-None
  • P-Simple
    • Programmable
  • M-Multi-
    • Programmable
  • C-Communicating
  • R-Rate
    • modulation
  • O-None
  • P-Pacing
    • (antitachy-
    • arrhythmia)
  • S-Shock
  • D-Dual
    • (P+S)
  • O-None
  • A-Atrium
  • V-Ventricle
  • D-Dual
    • (A+V)

Manufac-

turer’s

Designation

Only

  • S- Single
    • (A or V)
  • S- Single
    • (A or V)
slide24

The NASPE/BPEG Generic (NBG)Code

Position

I

II

III

IV

V

Category

Chamber(s)

Paced

Response

to Sensing

Programmability,

rate modulation

Antitachy-

arrhythmia

Function(s)

Chamber(s)

Sensed

Letters

Used

  • O-None
  • A-Atrium
  • V-Ventricle
  • D-Dual
    • (A+V)
  • O-None
  • T-Triggered
  • I-Inhibited
  • D-Dual
    • (T+I)
  • O-None
  • P-Simple
    • Programmable
  • M-Multi-
    • Programmable
  • C-Communicating
  • R-Rate
    • modulation
  • O-None
  • P-Pacing
    • (antitachy-
    • arrhythmia)
  • S-Shock
  • D-Dual
    • (P+S)
  • O-None
  • A-Atrium
  • V-Ventricle
  • D-Dual
    • (A+V)
  • S- Single
    • (A or V)

Manufac-

turer’s

Designation

Only

  • S- Single
    • (A or V)
slide25

The NASPE/BPEG Generic (NBG) Code

Position

I

II

III

IV

V

Category

Chamber(s)

Paced

Response

to Sensing

Programmability,

rate modulation

Antitachy-

arrhythmia

Function(s)

Chamber(s)

Sensed

Letters

Used

  • O-None
  • A-Atrium
  • V-Ventricle
  • D-Dual
    • (A+V)
  • O-None
  • T-Triggered
  • I-Inhibited
  • D-Dual
    • (T+I)
  • O-None
  • P-Simple
    • Programmable
  • M-Multi-
    • Programmable
  • C-Communicating
  • R-Rate
    • modulation
  • O-None
  • P-Pacing
    • (antitachy-
    • arrhythmia)
  • S-Shock
  • D-Dual
    • (P+S)
  • O-None
  • A-Atrium
  • V-Ventricle
  • D-Dual
    • (A+V)
  • S- Single
    • (A or V)

Manufac-

turer’s

Designation

Only

  • S- Single
    • (A or V)
slide26

The NASPE/BPEG Generic (NBG) Code

Position

I

II

III

IV

V

Category

Chamber(s)

Paced

Response

to Sensing

Programmability,

rate modulation

Antitachy-

arrhythmia

Function(s)

Chamber(s)

Sensed

Letters

Used

  • O-None
  • A-Atrium
  • V-Ventricle
  • D-Dual
    • (A+V)
  • O-None
  • T-Triggered
  • I-Inhibited
  • D-Dual
    • (T+I)
  • O-None
  • P-Simple
    • Programmable
  • M-Multi-
    • Programmable
  • C-Communicating
  • R-Rate
    • modulation
  • O-None
  • P-Pacing
    • (antitachy-
    • arrhythmia)
  • S-Shock
  • D-Dual
    • (P+S)
  • O-None
  • A-Atrium
  • V-Ventricle
  • D-Dual
    • (A+V)
  • S- Single
    • (A or V)

Manufac-

turer’s

Designation

Only

  • S- Single
    • (A or V)