CARDIOVASCULAR TEAM SYMPOSIUM 2017 - … TEAM SYMPOSIUM 2017: ... •Cardiac Resyncronization...
Transcript of CARDIOVASCULAR TEAM SYMPOSIUM 2017 - … TEAM SYMPOSIUM 2017: ... •Cardiac Resyncronization...
CARDIOVASCULAR TEAM
SYMPOSIUM 2017:Applying a Cardiovascular Team Approach to Daily Practice
Saturday, November 4th, 2017
Francisco Aguilar MD, FACC, FHRS
Cardiac Clinical Electrophysiology
AMITA Health Medical Group Heart and Vascular
CARDIOVASCULAR
TEAM SYMPOSIUM 2017
Everything You Wanted To Know About
Cardiac Pacing But Were Afraid To Ask
Disclosures
• Principal Investigator for the GLORIA-AF
registry funded by Boerhringer Ingelheim.
• Sub-Principal Investigator MINT Study.
• Sub-Principal Investigator MPP Trial.
• History of Cardiac Pacing
• Mechanics of Modern Pacing
• Clinical Pearls / Cases / Questions
• Directions for the Future
Everything You Wanted To Know About
Cardiac Pacing But Were Afraid To Ask
• History of Cardiac Pacing
• Mechanics of Modern Pacing
• Clinical Pearls / Cases / Questions
• Directions for the Future
Everything You Wanted To Know About
Cardiac Pacing But Were Afraid To Ask
History of Cardiac Pacing
• 1st Clinical Electrical Cardiac Activation - 1928
– Mark C. Lidwell (Australian anesthesiologist)
– Used alternating electrical current and a needle to
start the heart of a newborn.
• First “Artificial Pacemaker” - 1932
– Albert Hyman (American physiologist)
– Used needles with epinephrine injected into the
heart to treat cardiac standstill.
– The action potential created by the needle that stuck
the heart.
Mittal. Ind J Thorac Cardiovasc Surg, 2005; 21: 236-249
Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.
First Hyman Device
Hyamn’s Device in a Box
Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.
First Artificial Pacemaker
• Hand-crank drove a DC current generator.
• The electrical impulses were directed into the
patient's right atrium through a bipolar needle
electrode introduced via an intercostal space.
• Pacing could be delivered at rates of 30, 60 or
120 per minute.
• Intended to start stillborn hearts.
• Not intended to treat symptomatic bradycardia.
Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.
“THE HYMENOTOR”
Popular Science. Self-Starter for Dead Man’s Heart (Oct, 1933)
History of Cardiac PacingSurgery Drives the Field
• 1949 - Wilfred Bigelow and John Callaghan of Canada
used hypothermia to induce asystole in order to perform
cardiac surgery.
– Problem: In the re-warming phase the heart would
not often restart.
– Eureka moment: Surgery on a dog. Heart restarted
by poking the heart with a probe.
– Result: Experimentation with sino-atrial pacing.
Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.
History of Cardiac Pacing
The Grass Stimulator• In the 1940s and 1950s
the principle device
available to generate a
variety of electrical
impulses for physical
stimulation was the
Grass Stimulator.
Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.
History of Cardiac Pacing
The HoppsPacemaker• John Hopps, an electrical
engineer, worked with the
National Research Council
of Canada.
• Designed first electronic
device acting as pacemaker.
• External unit driven by
vacuum tubes.
• Electrical impulses were
transmitted via a bipolar
catheter electrode to the
atria using a transvenous
approach.
Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.
History of Cardiac Pacing
External Pacing
• Paul M. Zoll in 1950 developed the first external
pacemaker building on Bigelow and Hopp’s work.
Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.
1952 – The Electrodyne PM-65.
Earl Bakken
• Electrical Engineer
• Co-Founder Medtronic
• TV Repairman
History of Cardiac Pacing1957 -The First Battery Operated Pacemaker
www.earlbakken.com
http://mcad-mural.blogspot.com/
“So small and light that it may be attached to and worn by
the patient…”
Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.
History of Cardiac Pacing1958 -The First Self Contained Implanted Pacemaker
Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.Arne Larsson
History of Cardiac Pacing
Arne Larsson• Hospitalized with CHB / frequent Stokes-Adams attacks for 6
months.
• He was having 20 to 30 attacks daily and his prognosis was poor.
• Else Marie Larsson pleaded with Ake Senning and Rune Elmqvist
Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.
The Surgeon The Engineer
Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.
Senning wrote:
“On the 8th October 1958, in the
evening, when there were no
extra people in the theatre, I
implanted the first pacemaker,
but it lasted only 8 hours.”
The second pacemaker
functioned well for about 1 week,
but suddenly failed from a lead
fracture.
History of Cardiac Pacing
Arne Larsson• Arne Larsson required:
– Five lead systems.
– 22 pulse generators of 11 different models.
• Died December 28th, 2001 at age 86 from Malignancy
• He outlived the surgeon and engineer who saved his life.
Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.
Pacers of the 60s
Pacers of the 70s
Nuclear Pacemakers
• Designed by multiple manufactures in the early
1970s.
Prutchi, D. Nuclear Pacemakers.
Pu - 238
Pacers of the 80s
Pacemakers of Today
• History of Cardiac Pacing
• Mechanics of Modern Pacing
• Clinical Pearls / Cases / Questions
• Directions for the Future
Everything You Wanted To Know About
Cardiac Pacing But Were Afraid To Ask
Mechanics of Modern Pacing
• Leads
• Device Systems
– Single Chamber
– Dual Chamber
– Biventricular
Leads
Kenny T. The Nuts and Bolts of Cardiac Pacing. Wiley-Blackwell. 2008.
Haynes et al. Cardiac Pacing, Defibrillation and Resynchronization. Wiley-Blackwell, 2013.
Fixation
Fixation
How do pacing leads sense and pace?
Device Systems
Single Chamber
Children’s Hospital of Wisconsin Website.
Device Systems
Dual Chamber
Children’s Hospital of Wisconsin Website.
Device Systems
Biventricular
Device Systems
Biventricular
www.nature.com
Device Systems
Biventricular
• Cardiac Resyncronization Therapy
– Block-HF:
• NYHA Class I, II, III / LVEF 30-50%, AV block
• CRT superior to RV pacing for: death, HF, ventricular
remodeling.
– MADIT-CRT
• NYHA Class I, II / LVEF <35%, LBBB
• CRT resulted in reduced HF hospitalizations, improved EF
• Two year analysis showed a mortality benefit over
conventional therapy.
• History of Cardiac Pacing
• Mechanics of Modern Pacing
• Clinical Pearls / Scenarios / Questions
• Directions for the Future
Everything You Wanted To Know About
Cardiac Pacing But Were Afraid To Ask
How does a pacer regulate heart
rate?
• Accelerometer.
– Piezoelectric crystal senses motion.
• Tissue contact crystal.
– Minute ventilation senses respiration characteristics.
What do magnets do to pacemakers?
• Magnets make the pacemaker pace
ASYNCHRONOUSLY at a set rate per the
manufacturer. Sensing is disabled.
What do magnets do to pacemakers?
What do magnets do to pacemakers?
Why use a magnet on a pacemaker?
• Check if a pacemaker has ample battery, needs
to be replaced or completely dead.
• When you want to make sure the pacemaker will
pace SURGERY.
What do magnets do to ICDs?
• Disable tachy-therapies.
– There will be no treatment for VT or VF.
– Pacing is NOT impacted.
– Permanent programming is not impacted.
Does any device need to be checked
before and after surgery?
• No.
• They should be checked in the office routinely
independent of surgery.
– Every three months.
• There should be instructions from the
cardiology office with respect to what do with
the device during surgery cautery.
• Programming changes cannot be made with a
magnet.
Noise
Kenny T. Paced ECG Interpretation. Wiley-Blackwell. 2009.
Does a pacemaker always have to
pace?
• No.
• Pacemakers regulate the heart rate by stimulating
the heart when it is too slow.
• Pacemakers can do very little for fast heart rates.
• Pacemakers have hysteresis settings what you
see is not always what you get.
• Many times we DO NOT want the patient to
pace.
• History of Cardiac Pacing
• Mechanics of Modern Pacing
• Clinical Pearls / Cases / Questions
• Directions for the Future
Everything You Wanted To Know About
Cardiac Pacing But Were Afraid To Ask
Directions for the Future
• Leadless Pacing
• HIS Bundle Pacing
Leadless Pacing
Leadless Pacing
• MICRA Pacing Study – 725 patients. 719
implants (99.2%)
– Freedom from device complications at one year 96%.
• Pacer Characteristics:
– Single chamber pacing.
– 10 year battery life.
– Rate responsiveness.
– Implant with a 23 F sheath.
St. Jude Nanostim
HIS Bundle Pacing
• Pacing methodology where there is from a
location higher on the conduction system to
take advantage of existing cardiac structures and
electrical pathways.
HIS Bundle Pacing
HIS Bundle Pacing
Minnesota Star Tribune.
HIS Bundle Pacing
HIS Bundle Pacing
Thank You !!!
References
• Mittal T. Pacemakers – A journey through the years. Indian J Thorac
Cardiovascular Surg, 2005; 21: 236-249.
• Popular Science. Self-Starter for Dead Man’s Heart (Oct, 1933)
• Aquilina O. A brief history of cardiac pacing. Images in Paediatric Cardiology.
2006;8(2):17-81.
• Furman S. Early History of Cardiac Pacing and Defibrillation. Indian Pacing
and Electrophysiology Journal, 2(1): 2-3 (2002).
• Prutchi, D. Nuclear Pacemakers.
• Kenny T. The Nuts and Bolts of Cardiac Pacing. Wiley-Blackwell. 2008.
• Kenny T. Paced ECG Interpretation. Wiley-Blackwell. 2009.
• Haynes et al. Cardiac Pacing, Defibrillation and Resynchronization. Wiley-
Blackwell, 2013.