CRM8: Permanent Pacing Implant Flashcards
List 3 bradycardia syndromes
Sinus node dysfunction
-Abnormality in sinus node impulse formation and propagation
Sick sinus syndrome
-Sinus bradycardia, sinus pause/arrest, AF
Atrioventricular block
-Partial or complete interruption of impulse from atria to ventricles
What symptoms indicate bradycardia syndromes?
-Syncope
-Dizziness/presyncope
-Dyspnoea
-Mental confusion
-Palpitations
What are the classes of recommendation?
Class I - recommended
Class IIa - should be considered
Class IIb - may be considered
Class 3 - not recommended
What are the levels of evidence?
A: Data from multiple RCTs/meta-analyses
B: Data from single RCT or large non-RCT
C: Consensus of opinion by experts and/or small studies
Class and evidence level for pacing in patients with permanent bradycardia
Class and evidence level for pacing in patients with intermittent bradycardia
Class and evidence for pacing in patients with BBB
Class and evidence for pacing in patients with undocumented reflex syncope
Class and evidence for pacing in patients with unexplained syncope
Types of bradycardias that can be paced
Who should you not put pacemaker in? (Class III)
-People with reversible causes of bradycardia
Mode selection in sinus node disease and AV block
In what conditions would you programme AAI?
-Chronotropic incompetence
-Sick sinus disease
-Normal AV node conduction
-Unlikely to develop an atrial arrhythmia
In what conditions would you programme VVI?
-No normal atrial rhythm
-Impaired AV conduction
-Slow/no ventricular rhythm
-Unable to have DDD due to vascular anatomy
-Ablate and pace for AF
-No AV synchrony - ventricular support
In what conditions would you programme DDD?
-Intact atria, conducting normally
-Intact or impaired AV conduction
-Slow or no ventricular rhythm
-Benefits from A-V synchrony
-Heart failure?? CRT-P
-Atrial dysrhythmias
Device, mode, class and level of evidence?
-DDD
-Programme AAIR for chronotropic incompetence
-Class I level B
Device, mode, class and level of evidence?
-VVIR
-Class I level B
Device, mode, class and level of evidence?
-DDD
-Class I level C
Device, mode, class and level of evidence?
-No permanent pacing
-Class 3
-Temporary pacing only if patient can’t cope
Clinical history and pre-assessment in pacing
-Symptom and pathophysiology history
-Results from diagnostic tests
-Choice of pacing mode
-ECG?
-Informed consent
Pre implant checklist
-Nil by mouth
-Venous access
-Antibiotic prophylaxis
-Skin prep
-Blood results - Hep/HIV/INR/Hb
Patient safety and pre op
-MDT - sign in check list
-Vital signs - ECG/BP/Oximetry
-Defib/pacing/pericardial tap kit
-Is patient comfortable/warm?
What are points of access for pacing procedure?
-Subclavian vein
-Axillary vein
-Cephalic vein
Cephalic cut-down vs Subclavian puncture
Cephalic cut-down:
-Less complications
-Less trauma
-Depends on size of vein
Subclavian puncture:
-Puncture
-Split sheath
-Traumatic
What are complications of subclavian puncture?
-Pneumothorax
-Haemothorax
-Air embolism
What are the lead positions?
Left bundle pacing
-Narrow QRS
-Doesn’t cause remodelling
-Atrial lead in the right atrial appendage
Why do we do AAI pace preference?
-Saves battery
-Prevents remodelling of ventricle
Which patients might not have right atrial appendage?
-Bypass graft
-Use active fixation leads
What do you measure on pacing system analyser (PSA) post implant?
-Sensing (P and R wave)
-Pacing threshold
-Lead impedance
-Lead stability
-Diaphragmatic and phrenic nerve stimulation
-Slew rate
-ST elevation (injury current)
What does ST depression on injury current indicate?
-Perforation
What is slew rate?
-How sharp the R wave is
-Maximum rate of change
-Higher = Better
-Expressed in Volts/second
Values for pacing, sensing, slew rate and impedance
Why do you get patient to cough?
-To test stability
Why do you pace at 10 volts?
-To test for diaphragmatic twitching
What do you check post implant?
-Confirm lead position
-Confirm appropriate function
-Confirm stimulation site
-Wound check, final tests, programming through device
Complications of pacing implant
-Pneumothorax
-Haemothorax
-Air embolism
-Haematoma
-Cardiac perforation
-Pericardial effusion/tamponade
-Subclavian crush
What complication is this?
Pneumothorax
What complication is this?
Haemothorax
-blood is white
What complication is this?
-Lead diplacement
-Lead break
What complication is this?
Subclavian crush
-Lead break
What complication is this?
Cardiac perforation
What complication is this?
Haematoma
What complication is this?
-Adherence
-Erosion
-Infection
Why is the ventricular lead implanted first?
-Can pace through ventricular lead if AV node is disturbed
How is permanent pacing different from temporary pacing?
Temporary:
-Can have alternative access site: femoral, internal jugular
-Used in TAVI
-Overdrive pacing to suppress an arrhythmia
-External
