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Understanding Bradyarrhythmias and Pacemaker Management: A Comprehensive Overview

This overview delves into bradyarrhythmias, their types, and the role of pacemakers in managing these conditions. It discusses interpreting various heart blocks, including first to third-degree blocks and associated syndromes such as sinus node dysfunction and atrial tachyarrhythmias. Key considerations for pacing indications, including reversible causes, are addressed along with critical concepts in cardiac resynchronization therapy (CRT). The principles of the heart block system and pacing systems are also outlined, providing a vital resource for medical students and practitioners.

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Understanding Bradyarrhythmias and Pacemaker Management: A Comprehensive Overview

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  1. Bradyarrhythmia’s, Pacemaker’s & Complex Devices Dr Chris McAloon Medical Student Teaching

  2. Overview • Interpreting Bradyarrhythmia’s • Different types of Bradyarrhythmia’s • Pacemakers • Complex Devices

  3. First Rule “ Always look at the patient”

  4. Conducting system

  5. Heart Blocks • NSR • Sinus brady • SSS • Sinoatrial block • Sinus arrest

  6. Heart Blocks • 1st degree • 2nd degree • Mobitz Type 1 • Mobitz Type 2 • 2:1, 3:1 AVB • 3rd degree • Fascicular block - LAD, RAD, TFB • LBBB, RBBB • AF, Flutter

  7. Reversible Causes of Slow Heart Rate • Drug therapy • Acute Myocardial Infarction • Hypothermia • Hypothyroidism • Athletic Heart • Vaso-vagal mechanisms

  8. 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

  9. 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

  10. 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?

  11. 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

  12. Third Degree/ Complete Heart Block

  13. 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

  14. First Degree Heart Block

  15. 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

  16. Mobitz Type 1/ Wenckebach

  17. 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

  18. Mobitz Type 2

  19. Mobitz 2 – 3:1 Block

  20. SA Slow Sinus Rate AV Block Atrial Tachy-arrhythmias

  21. Pacemaker’s

  22. Pacing Indications

  23. Paced Patients: Predominant ECG Indication BPEG / HRUK National Database 2003 - 4

  24. Paced Patients: Predominant Presenting Symptom BPEG / HRUK National Database 2003-4

  25. 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

  26. 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

  27. Pacemaker Basic’s

  28. A Unipolar System

  29. A Bipolar System

  30. What is the PPM?

  31. What is the PPM?

  32. What is the PPM?

  33. What is the PPM?

  34. Electrodes -- Fixation Mechanism • Passive Fixation Mechanism – Endocardial • Tined • Finned • Canted/curved

  35. Electrodes – Fixation Mechanism • Active Fixation Mechanism – Endocardial • Fixed screw • Extendible/retractable

  36. 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

  37. A 1% A Lead only 55% A + V Leads (Dual Chamber) 44% V Lead only (mostly in AF) V lead normally @ RV apex V

  38. Complex Devices

  39. Complex Devices

  40. What can be done?

  41. What can be done?

  42. Technology

  43. 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

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