Pacemakers
Outline
1.Energy calculation 2.Pacemaker codes 3.Pacemaker configurations 4.Indications for pacemakers 5.Problems with pacemakers 6.Examples 7.Battery 8.Recent trends 9.Leads and electrode
Implantable pacemakers
Fixed Rate Demand R-Wave triggered Ventricular inhibited Atrial triggered Dual chamber
Pacemakers
Energy Calculation
Ep=(Vs2/RH) TD + VS IDT Ep - Energy delivered by the pacemaker to the heart during each pulse Vs Voltage RH Electrode heart resistance TD Pulse duration ID Drain current T- time period between successive pulse
Pacemaker Codes
Position Function 1 Chambers Paced 2 Chambers Sensed O 3 Response to Sensed Stimulus O 4 Rate Modulation? O (non-rate responsive)
R (rate responsive)
O (none)
A (atrium)
T (triggered)
V (ventricle)
I (inhibited)
D (both atrium & ventricle)
Pacemaker Configurations VOO
Indications Temporary mode some-times used during surgery to prevent interference from electrocautery
Pacemaker Configurations VVI
Indications The combination of AV block and chronic atrial arrhythmias (particularly atrial fibrillation).
Pacemaker Configurations AAI
Indications Sick sinus syndrome in the absence of AV node disease or atrial fibrillation.
Pacemaker Configurations VDD
Indications AV block with intact sinus node function (particularly useful in congenital AV block).
Pacemaker Configurations DDD
Indications 1. The combination of AV block and SSS. 2. Patients with LV dysfunction and LV hypertrophy who need coordination of atrial and ventricular contractions to maintain adequate CO.
Indications for Pacemaker
Class I 1. Sinus node dysfunction with documented symptomatic bradycardia 2. Symptomatic chronotropic incompetence (failure to increase HR with exercise or increased metabolic demand) 3. 3 and advanced 2 AV block associated with any of the following: Arrhythmias that require drugs resulting in symptomatic bradycardia Sinus pauses > 3 seconds Asymptomatic escape rate < 40bpm while awake 4. 3 or 2 AV block with associated symptomatic bradycardia 5. Type II 2 AV block with wide QRS, regardless of symptoms
Indications for Pacemaker
Class IIa 1. Syncope of unexplained origin when major abnormalities of sinus node function are discovered or provoked during EP studies. 2. Asymptomatic 3 AV block with an awake ventricular rate > 40bpm 3. Asymptomatic type II 2 AV block
Problems with Pacemakers Failure to Capture
Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.
Causes:
Threshold rise (electrolytes, drugs) Lead dislodgement Lead fracture RV infarct
Problems with Pacemakers Failure to Pace
Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.
Causes:
Oversensing Battery failure Internal insulation failure Conductor coil fracture
Problems with Pacemakers Failure to Pace
Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.
Causes:
Crosstalk
Problems with Pacemakers Failure to Sense
Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.
Causes:
Undersensing Lead Fracture
Example 1
The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/
Ventricular sensed, ventricular paced Consistent with VVI
Example 2
The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/
Atrial sensed, ventricular paced Consistent with DDD or VDD
Example 3
The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/
Atrial paced Consistent with AAI or DDD
Example 4
The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/
Failure to Pace
Example 5
The Alan E. Lindsay ECG Learning Center ; http://medstat.med.utah.edu/kw/ecg/
Failure to Sense
Pacemaker Battery
Mercury Batteries Biological power sources Nuclear batteries
o o
Plutonium 238 (Half life of 87 years) 2Li+I2= 2LiI+e
Lithium cells
Battery energy in joule
(A-H Rating)* VS * 3600 (s/h) Joules
Life time of a battery
(battery energy in joule/Energy delivered in each pulse)* T Sec Life time * (1/3600)* (1/24) *(1/365) Years
Recent trends
Programmable Pacemakers Rate responsive
Leads and electrode
Myo cardial Outside wall Endo cardial inside wall
o o o o
Sutureless Tined Porous tip Steriod eluting
