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Principles of Cardiac Pacing

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

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  1. Principles of Cardiac Pacing Seoul National University Hospital Department of Thoracic & Cardiovascular Surgery

  2. Cardiac Conduction System

  3. Cardiac Conduction System Bundle of His Right and Left Bundle Branches

  4. Coronary Artery Disease • Idiopathic Degeneration • Calcification • Endocarditis • Heart Surgery • RF Ablation Factors Influencing Conduction System

  5. Brief Indications of Cardiac Pacing

  6. 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

  7. 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

  8. 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

  9. 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

  10. Sick Sinus Syndrome • Sinus bradycardia • Sinus arrest • Sinoatrial exit block • Atrial fibrillation with a slow ventricular response • Tachy-brady syndrome

  11. Sinus Bradycardia

  12. Sinus Arrest & Sinoatrial Exit Block Sinus Arrest SA Exit Block

  13. Atrial Fibrillation with Slow Ventricular Response

  14. Tachycardia-Bradycardia Syndrome

  15. Second Degree A-V Block • Mobitz Type I (Wenckebach) • Mobitz Type II

  16. Third Degree A-V Block

  17. Congenital Third Degree A-V Block

  18. NASPE / BPEG (NBG) Pacemaker Code

  19. 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

  20. 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)

  21. 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)

  22. 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)

  23. 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)

  24. 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)

  25. 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)

  26. 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)

  27. Pacing Systems

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