17 PacemakersandICD YegaRamanMDFall2012-Kc13
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Transcript of 17 PacemakersandICD YegaRamanMDFall2012-Kc13
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Pacemakers and Implantable Cardioverter Defibrillators
Dr. Sivaraman Yegya-Raman
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Temporary and Permanent Cardiac Pacing
• Introduction• Temporary pacing : Indications, Technique• Permanent Pacing : Nomenclature Indications Pacing for Hemodynamic Improvement Pacemaker Implantation, Complications • Implantable Cardioverter Defibrillator
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Temporary Cardiac Pacing
• Transvenous• Transcutaneous• Epicardial• Transesophageal
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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
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Temporary Transvenous Pacing Electrograms
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Permanent Pacing
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The Pacemaker System
• PatientLead
Pacemaker
• Programmer
LeadLead PacemakerPacemaker
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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
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Castle LW, Cook S: Pacemaker radiography. In Ellenbogen KA, Kay GN, Wilkoff BL [eds]: Clinical Cardiac Pacing. Philadelphia, WB Saunders, 1995, p 538.Castle LW, Cook S: Pacemaker radiography. In Ellenbogen KA, Kay GN, Wilkoff BL [eds]: Clinical Cardiac Pacing. Philadelphia, WB Saunders, 1995, p 538.
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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
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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
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Codes Describing Pacemaker Modes
PositionPosition 11 22 33 44 55FunctionFunction ChambeChambe
rs Pacedrs PacedChamberChambers Senseds Sensed
ResponsResponse to e to SensingSensing
Rate Rate ModulatiModulationon
MultisitMultisite e pacingpacing
Specific Specific DesignatiDesignati
onsons
OO=none=none
AA=Atrium=Atrium
VV=Ventric=Ventriclele
DD=Dual-=Dual-Atrium Atrium and and VentricleVentricle
OO=none=none
AA=Atrium=Atrium
VV=Ventricl=Ventriclee
DD=Dual-=Dual-Atrium and Atrium and VentricleVentricle
OO=none=none
TT=Trigger=Triggereded
II=Inhibite=Inhibitedd
DD=Dual-=Dual-Triggered Triggered and and InhibitedInhibited
OO=none=none
RR=Rate =Rate modulationmodulation
OO=none=none
AA=Atriu=Atriumm
VV=Ventri=Ventriclecle
DD=Dual-=Dual-Atrium Atrium and and VentricleVentricle
NASPE/BPEG 2002
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DDD
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Indications for Pacing for AV BlockDegreeDegree Pacemaker necessaryPacemaker necessary Pacemaker Pacemaker
probably probably necessarynecessary
Pacemaker not Pacemaker not necessarynecessary
ThirdThird Symptomatic congenital Symptomatic congenital complete heart blockcomplete heart block
Aquired symptomatic complete Aquired symptomatic complete heart blockheart block
Atrial fibrillation with complete Atrial fibrillation with complete heart blockheart block
Acquired asymptomatic Acquired asymptomatic complete heart blockcomplete heart block
SecondSecond Symptomatic type ISymptomatic type I
Symptomatic type IISymptomatic type II
Asymptomatic Asymptomatic type IItype II
Asymptomatic Asymptomatic type I at intra-His type I at intra-His or infra-His levelsor infra-His levels
Asymptomatic type Asymptomatic type I at supra-His (AV I at supra-His (AV nodal) blocknodal) block
FirstFirst Asymptomatic or Asymptomatic or symptomaticsymptomatic
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Indications for Pacing for Sinus Node Dysfunction
PacemakerPacemaker Pacemaker probably Pacemaker probably necessarynecessary
Pacemaker not Pacemaker not necessarynecessary
Symptomatic bradycardiaSymptomatic bradycardia Symptomatic patients with Symptomatic patients with sinus node dysfunction sinus node dysfunction with documented rates of with documented rates of <40 bpm without a clear-<40 bpm without a clear-cut association between cut association between significant symptoms and significant symptoms and the bradycardiathe bradycardia
Asymptomatic sinus node Asymptomatic sinus node dysfunctiondysfunction
Symptomatic sinus Symptomatic sinus bradycardia due to long-bradycardia due to long-term drug therapy of a term drug therapy of a type and dose for which type and dose for which there is no accepted there is no accepted alternativealternative
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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?
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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
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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
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“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
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Sources of Electromagnetic Interference
• Medical– MRI– Lithotripsy– Electrocautery/
cryosurgery– External defibrillators– Therapeutic radiation
• Nonmedical– Arc welding
equipment– Automobile engines– Radar Transmitters
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Biventricular Pacing
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Normal Conduction Is Important
• 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
Sinusnode
AVnode
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Cardiomyopathy, LBBB, Heart Failure
Sinus node
AVnode
• Delayed lateral wall contraction
• Disorganized ventricular contraction
• Decreased pumping efficiency
Conduction block
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Heart FailureBifocal Ventricular Pacing
Sinus node
AVnode
• Intraventricular Activation • Organized ventricular
activation sequence• Coordinated septal and
free-wall contraction• Improved pumping
efficiency
Stimulation therapy
Conduction block
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Bi-Ventricular Pacing
Coronary sinus lead
Right atrial lead
Right ventricular lead
N Engl J Med 2003
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LV lead
RV coil
SVC coil
RA lead
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LV lead
RV lead
RA lead
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Bi-V Pace
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Implantable Cardioverter Defibrillator (ICD)
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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.
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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
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Ellenbogen K A, 2007Ellenbogen K A, 2007
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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
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“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 implantationB. Implanting an ICD C. Implanting an ICD with biventricular pacing
capabilities (3 leads)
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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
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1° Prevention: Clinical Device AlgorithmIf Non –Ischemic Dilated Cardiomyopathy:
If LVEF ≤ 35%, CHF Class III-IV, QRS≤ 35%, CHF Class III-IV, QRS ≥ 120 ms≥ 120 ms
ICD
ACE inhibitors, Beta Blockers
& EF ≤ 35%≤ 35%
BiV ICD
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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
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Future Directions
• Leadless pacing• Biological pacemakers• Subcutaneous ICD