Artificial Pacemak

er

Naida Dizon, RNChristopher Mauricio,RN

Jessix Pelenio,RN

•Definition-a device that delivers an electrical

stimulus from a pulse generator via a lead wire system to the heart muscle causing depolarization of the myocardium.

Significance:

-The pacemaker initiates and maintains the heart rate when the natural pacemakers of the heart are unable to do so.

Clinical Indications:

1.Symptomatic bradyarrhythmias• Sinoatrial bradyarrhythmias• Sinoatrial arrest• Sick sinus syndrome2. Heart block• Second degree heart block• Complete heart block

3. Prophylaxis• Following acute MI;

arrhythmias and conduction defects

• Before or following cardiac surgery

• During coronary arteriography

• Before permanent pacing4. Tachyarrhythmias• Supraventricular• Ventricular

Artificial pacemaker therapy

Pacemaker Design and Types

Electronic Pulse Generator• Contains the circuitry and batteries that

determine the rate and strength or output of the electrical stimulus delivered to the heart.

• Implanted in a subcutaneous pocket created in the pectoral region or below the clavicle.

Pacemaker Electrode• Leads can be threaded through a major vein into

the right ventricle or they can lightly sutured onto the outside of the heart and brought through the chest wall during open heart surgery.

• Endocardial leads may be temporarily or permanently placed and connected to a permanent/temporary generator. 

Fixation mechanisms of the Electrode

Passive fixationWingtips

Active fixationScrew

Active fixationTines

Pacemaker Generator Functions

VVI

AAI

DDD

DIFFERENT TYPES OF PACEMAKER

• use only.FLV

TEMPORARY PACEMAKER

• INVASIVE• NON-INVASIVE

INVASIVE PACEMAKER

Transvenous Pacing• A physician inserts a pacing catheter into the right

ventricle via the venous system. The catheter is connected to an external pulse generator.

Epicardial Pacing• Applied by using transthoracic approach.

Temporary wires are sutured loosely to the outermost layer of the heart and then exposed through the skin. These lead wires are then connected to an external pulse generator.

Transesophageal Pacing• An electrode is placed in the esophagus through the

nose or by a pill-electrode which is swallowed. The electrode is advanced to approximately the mid-esophageal level and atrial pacing is attempted at this point. If unsuccessful, then the position of the electrode is adjusted until pacing capture is obtained.

Percutaneous Transthoracic Pacing• Physician inserts a pacing wire or catheter into the right

ventricle via a percutaneous needle through the anterior chest. An external pulse generator sends the electrical impulses through the catheter to depolarize the right ventricle.

• C:\6\word6\CARDIO\Getting a Pacemaker.FLV

Non-invasive pacemakerNon-invasive Pacing• Used for emergency treatment of

symptomatic bradycardia.

• Electrical current is passed from an external pulse generator via a conducting cable and externally applied self-adhesive electrodes through the chest wall and heart.

Three Broad Categories For the Application of Non-invasive

Pacing

1.Emergency use2.Alternative3.Standby Use

Two Pacing Modes

1.Demand Pacing2.Non-Demand Pacing

• Noninvasive Transcutaneous Cardiac Pacing.FLV

Permanent pacing

• They are implanted into the body because of a permanent conduction problem.

• One or two pacing lead wires are placed via the venous system into the right ventricle or atrium.

• May pace a single chamber activating the atria or ventricle or may be dual chamber activating the atria and the ventricles

Complications of pacemaker use

• Local infection• Bleeding and hematoma• Hemothorax from puncture of the

subclavian vein or internal mammary artery.

• Ventricular ectopy and tachycardia• Perforation of the myocardium• Phrenic nerve, diaphragmatic or skeletal

muscle stimulation• Cardiac tamponade from bleeding• Dislodgement of the electrode• Pacemaker malfunction

Pacemakers: client education

• Monitor pacemaker function• Emphasize the importance of reporting to physician or

pacemaker clinic periodically as prescribed.• Educate the client on how to take the pulse and instruct

him/her to check it daily and report immediately for any sudden slowing or increasing of the pulse rate.

• Instruct the client to resume more frequent monitoring when battery depletion is anticipated.

• Promote safety and avoid infection• Instruct client to wear loose fitting clothing around the area of

the pacemaker.• Instruct client to notify physician if the pacemaker area

becomes red or painful.• Instruct to avoid trauma to the area of the pacemaker

generator.• Avoid contact sports.• Advise client to carry medical identification indicating

physician’s name, pacemaker rate and hospital where the pacemaker was inserted.

• Hospitalization may be necessary periodically to change battery or replace Educate the patient regarding electromagnetical interferences

• Avoid large magnetic fileds such as those surrounding MRI, large motors, arc welding and electrical substations.

• pacemaker unit.

ASSESSING PACEMAKER FUNCTIONING

Problem Possible causes Intervention

Loss of capture-complex does not follow pacing spike

Inadequate stimulus Lead dislodgement Lead wire fracture Catheter malposition Battery depletion Electronic insulation

break Medication change Myocardial ischemia

Check security of all connections; increase milliamperage

Reposition extremity; turn patient to side

Change battery Change generator

Undersensing-pacing spike occurs at preset interval despite patient’s intrinsic rhythm

Sensitivity too high Electrical interference

(e.g. by a magnet) Faulty generator

Decrease sensitivity Eliminate interference Replace generator

Oversensing-loss of pacing artefact; pacing does not occur at preset interval despite lack of intrinsic rhythm

Sensitivity too low Electrical interference Battery depletion Change in medication

Eliminate interference Change battery

Loss of pacing-total absence of pacing spikes

Oversensing Battery depletion Loose or disconnected

wires perforation

change battery check security of all connection apply magnet over permanent

generator Obtain 12 lead ECG and portable chest

x-ray. Assess for murmur. Contact physician

Change in pacing QRS shape

Septal perforation Obtain 12 lead ECG and portable chest x-ray. Assess for murmur. Contact physician