Muhammad Diah

Instalasi Kateterisasi Jantung

Cardiology Sub Div, Depart Internal Medicene
RSUD Zainoel Abidin, Banda Aceh
Cardiology Sub Div, Depart Internal Medicene
RSHM Palembang
1
ECG - Pacemakers
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*First described in 1952
*Introduced into clinical practice in 1960
*First endocardial defibrillators in 1980
*1991 in USA 1 million people had permanent
pacemakers
*Now
- Approximately 3 million with pacemakers
- Approximately 1 million with ICD device

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*Indications
*Basics, Pacemaker Components and Code
*ECG in Pacemaker

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*Provides electrical stimuli to cause cardiac
contraction when intrinsic cardiac activity is
inappropriately slow or absent
*Sense intrinsic cardiac electric potentials

* Stimulate cardiac depolarization
* Sense intrinsic cardiac function
* Respond to increased metabolic demand by
providing rate responsive pacing
* Provide diagnostic information stored by the
pacemaker
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Clinical Indication
for Pacer
1. Symptomatic bradycardia
2. Symptomatic heart block
- 2
nd
degree heart block
- 3
rd
or complete heart block
- Bifasicular or transfasicular bundle
branch blocks.
3. Prophylaxis


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*
*Pulse Generator
*Electronic Circuitry
*Lead System
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Lead
Pace
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* Subcutaneous or submuscular
* Lithium battery
* 4-10 years lifespan
* long life and gradual decrease in power
sudden pulse generator failure is an
unlikely cause of pacemaker malfunction
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PPM
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* Sensing circuit
* Timing circuit
* Output circuit
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Bipolar
*Lead has both negative,
(Cathode) distal and
positive, (Anode) proximal
electrodes
*Separated by 1 cm
*Larger diameter: more
prone to fracture
*Compatible with ICD
Unipolar
* Negative (Cathode)
electrode in contact
with heart
* Positive (Anode)
electrode: metal casing
of pulse generator
* Prone to oversensing
* Not compatible with
ICD
*current travels only a
short distance
between electrodes
*small pacing spike:
<5mm
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+
-
Anode
Cathode
*current travels a
longer distance
between electrodes
*larger pacing spike:
>20mm
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-
Anode
Cathode
+
-
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I
Chamber
Paced
II
Chamber
Sensed
III
Response
to Sensing
IV
Programmable
Functions/Rate
Modulation
V
Antitachy
Function(s)
V: Ventricle V: Ventricle T: Triggered
P: Simple
programmable
P: Pace
A: Atrium A: Atrium I: Inhibited
M: Multi-
programmable
S: Shock
D: Dual (A+V) D: Dual (A+V) D: Dual (T+I) C: Communicating D: Dual (P+S)
O: None O: None O: None R: Rate modulating
O: None
S: Single
(A or V)
S: Single
(A or V)
O: None
*1
st
letter chamber paced
*2
nd
letter chamber sensed
*3
rd
letter Response to chamber sensed
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*AAT
*Paces atria
*Senses atria
*Triggers generator to fire if atria sensed
*VVI
Ventricular Pacing : Ventricular sensing; intrinsic
QRS Inhibits pacer discharge
*VVIR
As above + has biosensor to provide Rate-
responsiveness
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*DDD
Paces + Senses both atrium + ventricle,
intrinsic cardiac activity inhibits pacer d/c, no
activity: trigger d/c
*DDDR
As above but adds rate responsiveness to
allow for exercise
*VVI
*Paces ventricle
*Senses ventricle
*Inhibited by a sensed ventricular event

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When the need for oxygenated blood increases,
the pacemaker ensures that the heart rate
increases to provide additional cardiac output
Adjusting Heart Rate to Activity
Normal Heart Rate
Rate Responsive Pacing
Fixed-Rate Pacing
Daily Activities
* Wallet card: 5
letter code
* CXR: code visible
* Single lead in
ventricle: VVI
* Separate leads
DDD or DVI
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*VVI - lead lies in
right ventricle
*Independent of atrial
activity
*Use in AV conduction
disease
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VVI / 60
*Typically in pts with
nonfibrillating atria and
intact AV conduction
*Native P, paced P, native
QRS, paced QRS
*ECG may be interpreted
as malfunction when
none is present
*May have fusion beats
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Rate = 60 bpm / 1000 ms
A-A = 1000 ms
AP
VP
AP
VP
V-A AV V-A AV
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Atrial Pace, Ventricular Pace (AP/VP)
Atrial Spike
Ventricular Spike
*
Rate = 60 ppm / 1000 ms
A-A = 1000 ms
AP
VS
AP
VS
V-A AV V-A AV
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Atrial Pace, Ventricular Sense (AP/VS)
AS
VP
AS
VP
Rate (sinus driven) = 70 bpm / 857 ms
A-A = 857 ms
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Atrial Sense, Ventricular Pace (AS/ VP)
V-A AV AV V-A
Rate (sinus driven) = 70 bpm / 857 ms
Spontaneous conduction at 150 ms
A-A = 857 ms
AS
VS
AS
VS
V-A AV AV V-A
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Atrial Sense, Ventricular Sense (AS/VS)


*EKG abnormalities due to
*Failure to output
*Failure to capture
*Sensing abnormalities
*Operative failures
*Definition
*No pacing spike present despite indication to
pace
*Etiology
*Battery failure, lead fracture, break in lead
insulation, oversensing, poor lead connection,
cross-talk
*Atrial output is sensed by ventricular lead
*Definition
*Pacing spike is not followed by either an atrial or
ventricular complex
*Etiology
*Lead fracture or dislodgement, break in lead
insulation, elevated pacing threshold, MI at lead
tip, drugs, metabolic abnormalities, cardiac
perforation, poor lead connection
*Oversensing
*Senses noncardiac electrical activity and is inhibited from
correctly pacing
*Etiology
*Muscular activity (diaphragm or pecs), EMI, cell phone
held within 10cm of pulse generator
*Undersensing
*Incorrectly misses intrinsic depolarization and paces
*Etiology
*Poor lead positioning, lead dislodgement, magnet
application, low battery states, MI
Due to pacemaker placement
*Pneumothorax
*Pericarditis
*Perforated atrium or ventricle
*Dislodgement of leads
*Infection or erosion of pacemaker pocket
*Infective endocarditis (rare)
*Venous thrombosis
Pacemaker syndrome
*Patient feels worse after pacemaker placement
*Presents with progressive worsening of CHF symptoms
*Due to loss of atrioventricular synchrony, pathway now
reversed and ventricular origin of beat
*Can interfere with function of pacemaker or
ICD
*Device misinterprets the EMI causing
*Rate alteration
*Sensing abnormalities
*Asynchronous pacing
*Noise reversion
*Reprogramming
Examples
*Metal detectors
*Cell phones
*High voltage power lines
*Some home appliances (microwave)
*Intensity of electromagnetic field decreases inversely
with the square of the distance from the source
*Newer pacemakers and ICDs are being built with
increased internal shielding
*CC: Chills, rigors
*HPI:
*65 yom c/o fevers, chills, rigors x 1 day.
Positive n/v and anorexia. Pt states he
had recent pacemaker insertion 4 days
ago for an arrhythmia.
*PMH:
*HTN
*Arrythmia
*Hypercholesterolemia
*PSHx:
*As stated above
*
*Physical exam
*Temp 101.2, HR 110, BP 90/55
*EKG




*Diagnosis?
*
*Pocket Infection
*Pacemaker insertion is a surgical procedure
*1% risk for bacteremia
*2% risk for pocket infection
*Usually occurs within 7 days of pacemaker
insertion
*May have tenderness and redness over
pacemaker site
*
*CC: SOB
*HPI:
*65 yom states he had onset of shortness
of breath and left sided pleuritic chest
pain. Pt states he awoke with pain and
difficulty breathing. Had pacemaker
placed yesterday.
*PMHx:
*HTN, Diabetes, Hypercholesterolemia,
Arrythmia, CAD
*PSHx:
*Pacemaker, left knee surgery, b/l
cataract
*
*Physical Exam
*BP 146/85, HR 80s, RR 30s, O2 Sat 88%
*Lungs
* Decreased breath sounds on left
*EKG





*Diagnosis?
*
*Pneumothorax
*Occurs during cannulation of central veins
*Incidence
*Cardiologist dependent
*Treatment
*Small or asymptomatic observation
*Large or symptomatic Chest tube
*
*CC: Cardiac arrest
*HPI: 59 yom found on couch. Wife states they
were watching TV when patient let out a moan
and then became unconscious. She states, he
has a bad heart and had something put in a
few years ago.
*PMHx: unknown
*Meds: bottles in bathroom
*
*Physical Exam
*Airway patent, no visible chest rise, no
pulses
*Generally: cool, clammy, diaphoretic
*EKG:





*Diagnosis?
*
*Cardiac Arrest with ICD (V-fib)
*2% annual incidence with ICD
*Etiology
*ICD delivered predetermined shocks for
identified event and patient failed to respond
*ICD failed to recognize event and failed to shock
appropriately
* Failure to sense, lead fracture, EMI, inadvertent ICD
deactivation
*
*Cardiac Arrest with ICD
*Treat using ACLS protocols
*Secure airway
*CPR
*Defibrillate/shock as warranted
* Keep sternal pad 10 cm away from pulse generator
*Meds