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Pacemakers and

Implantable Cardioverter
Defibrillators
Dr. Sivaraman Yegya-Raman

Temporary and Permanent Cardiac


Pacing
Introduction
Temporary pacing : Indications, Technique
Permanent Pacing :
Nomenclature
Indications
Pacing for Hemodynamic Improvement
Pacemaker Implantation, Complications

Implantable Cardioverter Defibrillator

Temporary Cardiac Pacing


Transvenous
Transcutaneous
Epicardial
Transesophageal

Indications for Temporary


Pacing
Acute myocardial infarction with:
CHB, Mobitz type 2 AV block,
medically refractory symptomatic
bradycardia, alternating BBB, new
bifascicular block, new BBB with anterior
MI
In absence of acute MI : SSS, CHB,
Mobitz type 2 AV block
Treatment of tachyarrhythmias : VT

Temporary Transvenous Pacing


Electrograms

Permanent Pacing

The Pacemaker System


Patient
Lead
Pacemaker
Programmer

Lead

Pacemaker

Pacemaker Implantation
Transvenous :
Generator implanted anterior to pectoral muscle
Atrial/Ventricular leads via subclavian or cephalic
vein
Sensing and pacing threshold
Chest X-ray for pneumothorax, lead position

Castle LW, Cook S: Pacemaker radiography. In Ellenbogen KA, Kay GN, Wilkoff BL [eds]: Clinical Cardiac Pacing. Philadelphia, WB Saunders, 1995, p 538.

Acute Complications of Pacemaker


Implantation
Venous access

Pneumothorax, hemothorax
Air embolism
Perforation of central vein
Inadvertent arterial entry

Lead placement

Brady tachyarrhythmia
Perforation of heart, vein
Damage to heart valve

Generator

Pocket hematoma
Improper or inadequate connection of lead

Delayed Complications of Pacemaker


Therapy

Lead-related

Thrombosis/embolization
SVC obstruction
Lead dislodgement
Infection
Lead failure
Perforation, pericarditis

Generator-related

Pain
Erosion, infection
Migration
Damage from radiation, electric shock

Patient-related

Twiddler syndrome

Codes Describing Pacemaker


Modes
Position

Function Chambe Chamber Respons Rate


rs Paced s Sensed e to
Sensing

Specific
Designati
ons

O=none
A=Atrium
V=Ventric
le
D=DualAtrium
and
Ventricle

O=none
A=Atrium
V=Ventricl
e
D=DualAtrium and
Ventricle

O=none
T=Trigger
ed
I=Inhibite
d
D=DualTriggered
and
Inhibited

Multisit
Modulati e
on
pacing
O=none
R=Rate
modulation

O=none
A=Atrium
V=Ventri
cle
D=DualAtrium
and
Ventricle

NASPE/BPEG 2002

DDD

Indications for Pacing for AV


Block

Degree

Pacemaker necessary

Third

Symptomatic congenital
complete heart block
Aquired symptomatic complete
heart block
Atrial fibrillation with complete
heart block
Acquired asymptomatic
complete heart block

Second

Symptomatic type I
Symptomatic type II

First

Pacemaker
probably
necessary

Pacemaker not
necessary

Asymptomatic
Asymptomatic type
type II
I at supra-His (AV
nodal) block
Asymptomatic
type I at intra-His
or infra-His levels
Asymptomatic or
symptomatic

Indications for Pacing for Sinus Node


Dysfunction
Pacemaker

Pacemaker probably Pacemaker not


necessary
necessary

Symptomatic bradycardia

Symptomatic patients
with sinus node
dysfunction with
documented rates of <40
bpm without a clear-cut
association between
significant symptoms and
the bradycardia

Symptomatic sinus
bradycardia due to longterm drug therapy of a
type and dose for which
there is no accepted
alternative

Asymptomatic sinus node


dysfunction

Case #1
72 year old male with chronic atrial
fibrillation of greater than 10 years
duration is admitted following a
syncopal episode. A 2D echo shows
LVEF 60%. Telemetry reveals atrial
fibrillation with slow ventricular
response and pauses of 5 to 6 seconds
associated with lightheadedness.
How would you proceed?

Case #1
72 year old male with chronic atrial
fibrillation of greater than 10 years
duration is admitted following a syncopal
episode. A 2D echo shows markedly dilated
left atrium and LVEF 60%. Telemetry
reveals atrial fibrillation with slow
ventricular response and pauses of 5 to 6
seconds associated with near syncope.
How would you proceed?
Answer: Implant a ventricular rate
responsive pacemaker

Pacemaker Follow-up
GOAL OF FOLLOW-UP
Verify appropriate pacemaker operation
Optimize pacemaker functions
Document findings, changes and final
settings in order to provide appropriate
patient management

Pacemaker Syndrome
Fatigue, dizziness, hypotension
Caused by pacing the ventricle asynchronously,
resulting in AV dissociation or VA conduction
Mechanism: atrial contraction against a closed
AV valve and release of atrial natriuretic
peptide
Worsened by increasing the ventricular pacing
rate, relieved by lowering the pacing rate or
upgrading to dual chamber system
Therapy with fludrocortisone/volume expansion
NOT helpful

Sources of Electromagnetic
Interference
Medical
MRI
Lithotripsy
Electrocautery/cryos
urgery
External
defibrillators
Therapeutic
radiation

Nonmedical
Arc welding
equipment
Automobile engines
Radar Transmitters

Biventricular Pacing

Normal Conduction Is
Important
Sinus
node

AV
node

Normal conduction
allows for prompt
and synchronous
activation of the
atria and ventricles
Results in a brief P
wave, PR interval
and a narrow QRS

Cardiomyopathy, LBBB, Heart


Failure
Sinus
node

AV
node
Conduction
block

Delayed lateral wall


contraction
Disorganized
ventricular
contraction
Decreased pumping
efficiency

Heart Failure
Bifocal Ventricular Pacing
Sinus
node

AV
node
Conduction
block

Intraventricular
Activation
Organized
ventricular
activation
sequence
Coordinated septal
and free-wall
contraction
Stimulation Improved pumping
therapy
efficiency

Bi-Ventricular Pacing
Right atrial lead

Coronary sinus lead

Right ventricular lead


N Engl J Med 2003

SVC coil

RA lead

LV lead

RV coil

RA lead

LV lead
RV lead

Bi-V Pace

Implantable Cardioverter
Defibrillator (ICD)

ICD Implantation
Secondary prevention: Prevention of
SCD in patients with prior VF or
sustained VT.
Primary prevention: Prevention of
SCD in individuals without a h/o VF or
sustained VT.

Indications For ICD


VF/sustained unstable VT not in the setting
of a completely reversible cause.
LVEF 35%, CHF NYHA class II, III.
Ischemic dilated cardiomyopathy, LVEF
40%, NSVT and inducible sustained VT.
Syncope, LV dysfunction, inducible
sustained VT.
High risk patients with: hypertrophic
cardiomyopathy, LQT syndrome, RV
dysplasia, Brugada syndrome

Ellenbogen K A, 2007

ACC/AHA/HRS 2008 Guidelines: Systolic Heart Failure Cardiac Resynchronization Therapy (CRT)
Recommendations

LVEF 35%
QRS 120 msec
NYHA functional Class III or
ambulatory Class IV
Optimal medical therapy

Typical Case
58 year old male, CAD, prior MI, EF 28%, CHF,
NYHA class II, Medications: Furosemide 40 mg,
Enalapril 20 BID, Aldactone 25 qd, Carvedilol 25
BID, no syncope or VT, ECG: Sinus rhythm, old
anteroseptal MI, QRS 92 msec
Based on available trial data, you would suggest:
A. Treating medically without device
implantation
B. Implanting an ICD
C. Implanting an ICD with biventricular pacing
capabilities (3 leads)

Typical Case
Q: 60 year old female presents with

a 1 year h/o non ischemic dilated


cardiomyopathy, CHF NYHA class III
despite maximum medical therapy,
LVEF 20% and LBBB with QRS 170
msec. What device is indicated?
A: Bi-Ventricular ICD

1 Prevention: Clinical Device


Algorithm
If Non Ischemic Dilated
Cardiomyopathy:
& EF 35%
ACE inhibitors, Beta Blockers

ICD

If LVEF 35%, CHF Class III-IV, QRS 120 ms

BiV ICD

Magnet Application on
Pacemaker/ICD
Pacemaker:
Disables sensing
Changes to VOO or DOO mode
Useful if cautery is being used in PPM dependent pt.

ICD:
Disables Tachycardia sensing
Useful at bedside if pt. has ventricular lead fracture
or Afib with rapid ventricular response causing ICD
shocks
Prevents ICD shock during cautery application at
surgery

Future Directions
Leadless pacing
Biological pacemakers
Subcutaneous ICD