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Cardiology Exam III > Cardiology 28: Pacemakers > Flashcards

Cardiology 28: Pacemakers Flashcards

1
Q

Pacemaker

A

Delivers electric pulses that cause a heart to beat

Increases or regulates a rhythm

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2
Q

Implantable Cardioverter Defibrillator

A

Delivers electric shocks to terminate fast rhythms
Can deliver anti-tachycardia pacing (ATP) to overdrive a fast rhythm
Also functions as a pacemaker

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3
Q

Pulse Generator

A

Contains a battery that provides the energy for sending electrical impulses to the heart

Houses the circuitry that controls pacemaker operations

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4
Q

Passive fixation

A

The tines become lodged in the trabeculae of the heart

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5
Q

Active fixation

A 
The helix (or screw) extends into the endocardial tissue
Allows for lead positioning anywhere in the heart’s chamber
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6
Q

The leads are applied directly to the heart by 3 mechanisms

A

Epicardial stab-in
Myocardial screw-in
Suture-on

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7
Q

Unipolar Pacing System

A

Contains a Lead with Only One Electrode Within the Hear

The impulse:

  1. Flows through the tip electrode (cathode)
  2. Stimulates the heart
  3. Returns through body fluid and tissue to the IPG (anode)
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8
Q

Bipolar pacing system

A

Contains a Lead with Two Electrodes Within the Heart.
The Impulse:
1.Flows through the tip electrode located at the end of the lead wire
2.Stimulates the heart
3.Returns to the ring electrode above the lead tip

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9
Q

Class I Indication

A

Conditions for which there is evidence and/or general agreement that permanent pacemakers should be implanted

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10
Q

Class II Indication

A

Conditions for which permanent pacemakers are frequently used but there is divergence of opinion with respect to the necessity of their insertion

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11
Q

Class III Indication

A

Conditions for which there is general agreement that pacemakers are unnecessary

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12
Q

List of Class I indications For SA node dysfunction

A
  1. Documented symptomatic sinus bradycardia, including frequent sinus pauses that produce symptoms. May be due to long-term drug therapy of a type and dose for which there is no accepted alternative
  2. Symptomatic chronotropic incompetence (of the sinus node)
Those include are :
1.Sinus bradycardia (symptomatic !)
   Syncope, passing out , dizziness.
2.Sinus arrest
3.Sinus pause (SA exit block)
   Greater than 3 seconds
4.Brady-tachy syndrome
5.Atrial flutter or atrial fibrillation with symptomatic       
bradycardia
6.Chronotropic incompetence
   Cant get it to increase with activity
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13
Q

List of Class II indications for SA node dysfunction

A

1a. Symptomatic patients with sinus node dysfunction and documented rates of < 40 bpm without a clear-cut association between significant symptoms and the bradycardia
AKS syncope, dizziness etc.
1b. In minimally symptomatic patients, chronic heart rate < 30 bpm while awake

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14
Q

Class III Indications for sinus node dysfunction(AKA not indicated)

A

Asymptomatic sinus node dysfunction or due to unnecessary drug therapy.

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15
Q

3rd degree heart block is a Class I indication for pacemaker in AV Block. what is associated with 3rd degree heart block ?

A

1.Symptomatic bradycardia (including those from arrhythmias and other medical conditions that require drug therapy)
2.Documented periods of asystole > 3 seconds
Escape rate < 40 bpm in awake, symptom free patients
3.Post AV junction ablation
4.Post-operative AV block not expected to resolve
5.Neuromusclar diseases with AV block

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16
Q

Second degree heart block associated with ________ becomes a class I indication for pacemaker in AV block.

A

symptomatic bradycardia

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17
Q

Class IIA indications for AV Block include:

A

Asymptomatic CHB with a ventricular rate > 40 bpm

Asymptomatic Type II 2nd degree AV block with narrow QRS complex

Asymptomatic Type I 2nd degree AV block within the His-Purkinje system found incidentally at EP study

First-degree AV block with symptoms suggestive of pacemaker syndrome and documented alleviation of symptoms with temporary AV pacing

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18
Q

Class IIB indications for AV Block include:

A

First degree AV block > 300 ms in patients with LV dysfunction in whom a shorter AV interval results in hemodynamic improvement

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19
Q

Class III indications for AV Block include

A

Asymptomatic 1st degree AV block

Asymptomatic Type I 2nd degree AV block at supra-His level

AV block expected to resolve and unlikely to recur (e.g., drug toxicity, Lyme Disease)

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20
Q

Class I indication for patients with Bifascicular and Trifascicular Block include

A

Intermittent 3rd degree AV block

Type II 2nd degree AV block

Alternating BBB (goes from right to left)

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21
Q

Class II Indication for Bifascicular and Trifascicular Block include

A

Syncope not proved to be due to AV block when other causes have been exluded, specifically VT

Prolonged HV interval ( >100 ms)
His to ventrical interval

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22
Q

Class III indication for Bifascicular and Trifascicular Block include

A

Asymptomatic fascicular block without AV block

Asymptomatic fascicular block with 1st degree AV block

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23
Q

Class I indications for Carotid Sinus and Vasovagal abnormality inclues

A

Recurrent syncope caused by carotid sinus stimulation; minimal carotid sinus pressure induces a period of asystole > 3 seconds in duration (CSS)

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24
Q

Class II indication for Carotid Sinus and Vasovagal abnormality inclues

A

Recurrent syncope without clear, provocative events (tilt table test) and with a hypersensitive cardioinhibitory response

Neurally mediated syncope with significant bradycardia reproduced by a head-up tilt table testing (VVS)

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25
Q

Class III indication for Carotid Sinus and Vasovagal abnormality inclues

A

Asymptomatic with a positive response to carotid sinus massage (CSS)

Recurrent syncope, lightheadedness, or dizziness without a cardioinhibitory response (CSS/VVS)

Situational vasovagal syncope in which avoidance behavior is effective

Vague symptoms such as dizziness, light-eadedness, or both, with hyperactive cardioinhibitory response to CS stimulation

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26
Q

Class I indications for AV Block Associated with Myocardial Infarction – Pacemaker Indications

A

Persistent and symptomatic 2nd or 3rd degree AV block

Persistent Type 2nd degree AV block in the His-Purkinje system with bilateral BBB or 3rd degree AV block within or below the His-Purkinje system

Transient advanced 2nd or 3rd degree infranodal AV block and associated bundle branch block

27
Q

Class II indications for AV Block Associated with Myocardial Infarction

A

Persistent 2nd or 3rd degree AV block at the AV node level

28
Q

Class III indications for AV Block Associated with Myocardial Infarction

A

Transient AV block in absence of intraventricular conduction defect
Pre-existing 1st degree AV block with bundle branch block

29
Q

Class I indications for Implabatable Cardioversive Defibrilator

A

Cardiac Arrest
Due to VT or VF
Not due to transient or reversible cause
Spontaneous sustained VT ( > 30 seconds)
Structural heart disease must be present
Syncope of undetermined origin with:
Sustained VT that has clinical relevance and/or
hemodynamic significance
VF induced during EP study when drug therapy
sustained VT is not preferred
Nonsustained VT with:
Coronary disease
Prior MI
LV Dysfunction
Inducible VF or sustained VT
(Non-suppressible by antiarrhythmic drugs)
Spontaneous sustained VT
Not amenable to other treatments

30
Q

Class IIa indications for Implabatable Cardioversive Defibrilator

A

LVEF <30% at:
1 month post MI
3 months post coronary revascularization

31
Q

Class IIB indications for Implabatable Cardioversive Defibrilator

A 
Cardiac Arrest 
   Assumed due to VF
   EP test precluded by other medical conditions
Symptomatic sustained VT while awaiting cardiac transplant
Conditions with life-threatening risk
   Long QT Syndrome
   Hypertrophic cardiomyopathy
Nonsustained VT with:
   Coronary disease
   Prior MI
   LV Dysfunction
   Inducible VF or sustained VT
Syncope of undetermined origin with:
   Ventricular dysfunction
   Inducible ventricular arrhythmias
   All other causes of syncope excluded
RBBB and ST Segment Elevation with:
   Syncope of unexplained origin, or
   Family history of SCD
Syncope and:
   Structural heart disease
    Extensive testing failed to identify cause
32
Q

Class III indications for Implabatable Cardioversive Defibrilator

A 
Syncope of undetermined origin
   Without structural heart disease 
   No inducible VT or VF
Incessant VT or VF 
  Don’t put them in, they will get shocked
  constantly
VT or VF with an ablatable or surgically treatable cause
   WPW, LVOT VT, ILVT, Fascicular VT
Transient or reversible VT
   Due to AMI, electrolyte imbalance, drugs or
   trauma
Psychiatric illness that may:
   Be aggravated by device implantation
   Preclude follow-up
Terminal illness 
   <6 month life expectancy
CAD and:
   LV dysfunction and Prolonged QRS, or
   Inducible VT in those undergoing bypass
33
Q

What are the two things that pacemakers do ?

A

Pace and Sense

34
Q

What are the three types of Pacemakers ?

A

SIngle chamber
Dual Chamber
Biventricular

35
Q

Describe a single chamber pacemaker system

A

The pacing lead is implanted in the atrium or ventricle, depending on the chamber to be paced and sensed (Pacing and sensing is in the same chamber)

36
Q

Describe a dual chamber pacemaker

A

One pulse generator with two pacing circuits
Circuit 1 for Atrial pacing and sensing
Circuit 2 for Ventricular pacing and sensing

37
Q

In pacing mode code, the first letter correlates to …

A

The Chamber being PACED (Ventricle, Atrium, Dual)

38
Q

In pacing mode code , the second letter correlates to …

A

The chamber SENSED (Ventricle, Atrium, Dual)

39
Q

In pacing mode code, the third letter correlates to

A

The mode of response (Triggered, Inhibited, Dual, None)

40
Q

In pacing mode code, the fourth letter correlates to…

A

Program function (Simple, Multi)

41
Q

In placing mode code, the fifth letter correlates to

A

Antitachyarryhthmia component (Pacing, Shocking,Dual)

42
Q

Intrinsic event

A

Cardiac events which come from the patient

43
Q

Inhibited

A

When the pacemaker stimulus is suppressed due to a spontaneous intrinsic event sensed before the end of the sensing (alert) period

44
Q

Pacing interval

A

The rate at which the pacemaker will pace if the patient does not have their own rhythm

45
Q

How do you calculate the pacing interval? Pacing Rate

A

Intended pacing rate / 60,000 = Interval (ms)

Interval /60,000

46
Q

Appropriate atrial sensing involves

A

Sensing of intrinsic P waves (restart the pacing interval)

47
Q

Appropriate ventricular sensing involves

A

Sensing intrinsic QRS waves (these restart the pacing interval)

48
Q

Capture

A

The depolarization and resultant contraction of the Atria or Ventricles in response to a pacemaker stimulus.

49
Q

What are the characteristics of atrial capture on EKG?

A

Inverted P wave, thin QRS complex

50
Q

What are the characteristics of ventricular capture on EKG ?

A

Wide QRS complex, elevated ST segment.

51
Q

Asynchronous Pacing

A

Pacing without sensing (continous pacing)

Often used in the OR ***

Often turned on in the presence of magnets **

52
Q

What is the characteristic of Asynchronous Pacing on EKG ?

A

Non-sensed P waves in-between beats

53
Q

VOO

A

Paces ventricle, senses none, no response given

54
Q

DOO

A

Paces atria and ventricles, senses neither, No response given

55
Q

Demand pacing

A

Pacing with sensing

Pacing pulse is inhibited by intrinsic “P” or “R-waves”

Sensed events reset the pacing interval

ie. Pacing only occurs when a pause occurs….

56
Q

AAI

A

Paced: Atria
Sensed: Atria
Response: Inhibited (by P waves)

57
Q

VVI

A

Paced: Ventricle
Sensed: Ventricle
Response: Ihibibited (R waves)

Pacing with sensing in the Ventricle which causes inhibition of the pacing stimulus and resets the pacing interval.

OFTEN DONE WHEN SOMEONE IS APT TO ATRIAL FIBRILLATION ! (Don’t give a crap about atria, make sure the ventricle is working correctly

58
Q

DDD

A

Paced: Dual
Sensed:Dual
Response: Inhibition in both

Ability to track Atrial activity in the Ventricular channel

59
Q

Purpose of dual chamber pacing ?

A

fill in the blanks for the patient.

In other words, if the patient doesn’t have a P-wave then the pacemaker will pace in the atrium
If the patient doesn’t have a R-wave then the pacemaker will pace in the ventricle

60
Q

Four States of Dual Chamber Pacing

A

AV: Atrial and Ventricular Pace
AR: Pace in Atrium, sense in ventricle
PV: Atrial sense and Ventricular Pace
PR: Sense in atria and Ventricle

61
Q

When would dual Atrial and Ventricular Pacing be needed ?

A

When paced P waves fail to elicit a QRS complex ventricular pacing will lead to depolarization

62
Q

Complications of Implantation

A 
Vascular Compromise
Pneumothorax
Hemothorax
Cardiac Perforation
Cardiac Tamponade
Sedation
63
Q

Post implantation complications

A 
Lead Dislodgement
Diaphragmatic Pacing
Pectoral Muscle Pacing
Brachial Plexus Injury
Infection
   Must take out the whole device.
Migration Of Device
Pacemaker-mediated Tachcardia
EMI

Cardiology Exam III (12 decks)

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