1_Basic Pacing General

7/27/2019 1_Basic Pacing General

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Basic Cardiac Pacing


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Pacemaker Indication

Pacemaker Codes & Modes

ECG

ConductionSystem

Anatomy


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The Heart

Muscular pump at thecenter of the circulatorysystem.

Average dimensions:13 x 9 x 6 cm

Weight: 300 grams Apex

Base


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Where is it ?

left lung right lung

sternum vertebral column

diaphragm


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What is it made of?


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How is it structured?

Right Atrium Left Atrium

Right Ventricle

Left Ventricle

Ventricles

Atria

Interventricular Septum

Trabeculae Carnae

Coronary Sinus


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Four Chambers

Right Atrium Left Atrium

Right Ventricle

Left Ventricle Tricuspid Valve

Mitral Valve


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Atrioventricular / Semilunar Valves

Atrioventricular Valves

Tricuspide Valve Mitral Valve

Semilunar Valves

Pulmonary Valve Aortic Valve


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Atrioventricular / Semilunar Valves

Ventricular Relaxation(Diastole)

LeftAtrium

LeftVentricle

Mitral Valve

AorticValve

Aorta

Ventricular Contraction(Systole)

LeftAtrium

LeVentri

AorticValve

Mitral Valve

Aorta


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Circulatory System : Right Side

Inferior Vena Cava (deoxygenated blood from

Legs & Internal organs)

Superior Vena Cava (deoxygenated bloodfrom Head & Arms)

Tricuspid Valve

Pulmonary Valve

To Left Lung To Right Lung

Pulmonary Arteries


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Circulatory System : Left Side

Aortic Valve

From Left Lung From Right Lung

(oxygenated bloodfrom Lungs)

Pulmonary Veins

Mitral Valve

To Head & Arms

To Body

Aorta


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The passage of blood through theheart


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Cardiac Output

Cardiac output = Amount of blood pumped by theheart per minute

Cardiac output = Heart rate x Stroke Volume

Shorter strokes Longer strokesamount of blood per beat

Slow Fast beats per minute


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The Autonomic Nervous System

Controls and regulates the heart and other internal organs It is composed of two sets of nerves:

SympatheticNervous System ParasympatheticNervous System

Prepares the bodyfor action(e.g., heart rate

increases)

Prepares the bodyfor inactivity(e.g., slows the

heart rate)


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ECG

Anatomy

ConductionSystem


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Response of a cell (muscle or nerve) to a stimulus

Heart cells are charged or polarized in the resting state.

Resting Polarized

When the cell relaxes is said to be repolarized.

+ ++ +

+ ++ +

RepolarizationRelaxation

When they are stimulated, they depolarize and contract

DepolarizationContraction + ++ + + ++ +

+ + +

+

+ + +

+

+ + +

+


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Conduction System

Atrio-Ventricular

(AV) Node

Sino-Atrial(SA) Node

Bundle of His

Right & LeftBundle Branches

Purkinje System


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Sino-Atrial (SA) Node Depolarization

Sino-Atrial Node


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Atrial Depolarization

Right Atrium

Left Atrium

SANode


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Atrio-Ventricular(AV) NodeDepolarization

Atrio-Ventricular Node


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Ventricular Depolarization

Bundle of His

Right & LeftBundle Branch

Purkinje fibers


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Pacemaker Activity of ElectricalConduction System


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ConductionSystem

Anatomy

ECG


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Electrocardiogram (ECG)

The ECG measures the electrical changes thattake place in the heart during each heartbeat.

These changes are detected by placingcombinations of electrodes on the surface of the skin, and recording the voltage differencebetween them.

ECGs provide information on the heartscondition and performance.


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ECG : The Three Lead Configuration

--- +

+ +

I

III II

Time


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The ECG Lead Setup


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Time versus Rate

Time is expressed in milliseconds (msec)

Rate is expressed in Beats Per Minute (bpm or ppm)

1 minute = 60 sec = 60,000 msec

Time = Rate =Rate Time

60,000 60,000


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ECG : P wave

VentricleElectrical Mechanical

AtriumElectrical Mechanical

Depolarization Systole(contraction)


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ECG : P-R segment



Systole(contraction)


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ECG : QRS complex


Depolarization Systole

(contraction)


Repolarization Dyastole(relaxation)


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ECG : ST segment


Systole

(contraction)


Dyastole(relaxation)


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ECG : T wave


Repolarization Dyastole

(relaxation)


Dyastole(relaxation)


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ECG : P-R and S-T Intervals


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ECG

ConductionSystem

Anatomy



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Pacemaker System

Pulse Generator Pacing Lead

PULSAR MAX

Right Atrium

Right Ventricle


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Single Chamber Pacing

Atrial Pacing Ventricular Pacing


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Dual Chamber Pacing


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Dual Chamber Stimulation

Advantages

Results

AV SynchronyVariability of the pacing rate

Increase of the cardiac outputImprove quality of life


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Pulse Generator

PULSAR MAX

Battery

Pacing Circuit

Sensing Circuit


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Lead Fixation

Active Fixationscrew -in

Passive Fixationwings

Passive Fixationtines


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Lead Fixation

Trabeculae Carnae


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NASPE/BPEG Pacemaker Code

1 st letter 2 nd letter 3 rd letter 4 th letter Chamber(s)

PacedChamber(s)

SensedResponse to

SensingProgrammability &Rate modulation

O = None

A = Atrium

V = Ventricle

D = Dual (A + V)

O = None

A = Atrium

V = Ventricle

D = Dual (A + V)

O = None

T = Triggered

I = Inhibited

D = Dual (T + I)

O = None

P = Simple programmability

M = Multi programmability

C = Telemetry

R = Rate Modulation

A four-letter code is generally used to identify the mode of operation


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Common Pacemaker Modes

Pacing Sensing Responseto Sensing Programmability& Rate Response

V O O

- Ventricular pacing

- No sensing

- No response to sensing


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V V I

- Ventricular pacing

- Ventricular sensing

- Inhibited when sensing a ventricular event


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V V I R

- Ventricular pacing - Ventricular sensing

- Inhibited when sensing a ventricular event

- Rate response capabilities


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D D D

- Dual (Atrial & Ventricular) pacing

- Dual (Atrial & Ventricular) sensing

- Dual (Inhibited & Triggered) response to sensing


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Programmability& Rate ResponsePacing Sensing Responseto Sensing

D D D R

- Dual (Atrial & Ventricular) pacing

- Dual (Atrial & Ventricular) sensing

- Dual (Inhibited & Triggered) response to sensing

- Rate Response Capabilities


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ECG

ConductionSystem

Anatomy



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Pacemaker Indications

Sinus Node Dysfunction (Sick Sinus Syndrome)

Atrioventricular (AV) Block

Binodal disease (Sinus Node disease with AVBlock)

Chronic Atrial Fibrillation(AF) with AV Block


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Sinus Node dysfunction

SA Node


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Choice of Pacemaker Model

Diagnosis Optimal Mode UnacceptableMode

Sinus Node Dysfunction AAI(R)DDD(R)

VVI(R)VDD(R)


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Atrioventricular (AV) Block

AV Node


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VVI(R)VDD(R)

AV block DDDVDD

AAI(R)DDI(R)


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Binodal Disease

AV Node SA Node


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VVI(R)VDD(R)

AV block DDDVDD

AAI(R)DDI(R)

Binodal Disease DDD(R) VVI(R) AAI(R)

VDD(R)

Ch i AF i h AV Bl k


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Chronic AF with AV Block

AV Node


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Diagnosis Optimal Mode UnacceptableModeSinus Node Dysfunction AAI(R)

DDD(R)VVI(R)

VDD(R)

AV Block DDDVDD

AAI(R)DDI(R)

Binodal Disease DDD(R) VVI(R) AAI(R)VDD(R)

Chronic AF with AV

Block

VVI(R) AAI(R)

DDD(R)VDD(R)


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Coffee Break !!!!!

Video How to Implant a Pacemaker ?

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1_Basic Pacing General

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