PowerPoint Chapter 13 Flashcards
What is a pacemaker?
Any device which sends electrical impulses to the heart to stimulate cardiac contraction when its intrinsic electrical system is not functioning normally.
In the event of missing electrical activity the pacemaker does what?
Sends an appropriate pulse of energy through electrodes to heart.
A pacemaker is 1 or more ____ placed in heart and connected to the ____ and activity ____?
A pacemaker is 1 or more leads placed in heart connected to the pacemaker and activity sensor
What is a CIEDs?
Cardiac Implantable Electronic Device
What is the dual purpose of a CIED?
Delivers a shock to the heart through the electrodes
Also functions as pacemaker
What are the three locations leads can be placed for a pacemaker?
Atrial lead (right atrium)
Left ventricular lead
Right ventricular lead
What are nine indications for a pacemaker
- Symptomatic pronounced 1deg (or type 2 av block)
- Mobitz type 2 AV block
- Third Degree Heart Block
- Symptomatic Bradycardia
- Symptomatic Chronotropic incompetence
- Permanent A-Fib with symptomatic Bradycardia
- Heart Failure
- Hypertrophic Obstructive Cardiomyopathy
- Syncope of unknown etiology with sinus node dysfunction uncovered or proved during Electrophysiology study.
What type of pacemaker will be used if someone has heart failure?
Biventricular Pacemaker
What device will be used if someone has Hypertrophic Obstructive Cardiomyopathy?
Implantable cardioverter defibrillator
What is Symptomatic Chronotropic incompetence?
Heart rate does not increase with exercise aka Exercise intolerance
What are the 2 general components of a pacemaker?
-Pulse Generator aka “the Can”
-Electrodes
What are the two parts of the Pulse Generator aka “the Can”?
Pulse Generator aka “the Can”
-Battery (lasting about 5 years)
-Control center (Circuitry)
What are the two parts of the electrodes in a pacemaker?
Electrodes
-Wires running from pulse generator to heart
-At the end of the electrode is a screw or hook for fixation
What are the general four types of pacemakers?
-External Pacemaker (Transcutaneous)
-Temporary Epicardial
-Temporary Endocardial (Transvenous)
-Permanent Pacemaker (subcutaneous)
What is a External Pacemaker and when is it used (another name and when used)?
External Pacemaker (Transcutaneous) – wires connected to pads on skin
Mainly used during emergencies
What is a temporary epicardial pacemaker (wires and when used)?
Temporary Epicardial – used during Heart surgery, wires going to outer heart wall
Assisting heart when irritated bc of surgery
What is a temporary endocardial pacemaker (another name, wires, and when used)?
Temporary Endocardial (Transvenous) – pulse generator outside wires implanted through subclavian vein to endocardial tissue inside heart
Temp abnormality- drug induced bradycardia, recreational drugs. Chest contusion, waiting for permanent Pacemaker
What is a permanent pacemaker (another name and when used)?
Permanent Pacemaker (subcutaneous)
Heart block 3rd deg or adv 2nd degree
Symptomatic Sinus bradycardia
What are the four types of pacemaker administrations?
-Single Chamber: RA or RV
-Dual chamber: RA + RV
-Biventricular: RA + RV + LV (triple chamber)
-Implantable Cardioverter Defibrillator
Describe a single chamber pacemaker?
Single Chamber: RA or RV
Right Atrium – AV conduction is normal. SA node is not
Right Ventricle – AV conduction is abnormal. Bypassing atrium for Vent. Contraction
Describe a dual chamber pacemaker?
Dual chamber: RA + RV
Right Atrium and Right Ventricle
Synchronizing contractions
Describe a biventricular pacemaker?
Biventricular: RA + RV + LV (triple chamber)
Right atrium, Right ventricle, Left Ventricle
Severe heart Failure
Synchronizing all chambers and improve heart function
Describe an implantable cardioverter defibrillator?
Implantable Cardioverter Defibrillator
Continually monitoring rhythm and able to shock when needed
What general feature appears on a pacemaker ECG?
Note the sharp vertical line on all leads.
What appears on an atrial pacemaker ECG?
Atrial Pacemaker
Line before P wave
What appears on a ventricle pacemaker ECG?
Ventricle Pacemaker
Line before QRS
What appears on a dual chamber ECG?
Dual chamber
Line before P wave and QRS
What are the four positions of a pacemaker chart?
- chamber paced
- Chamber sensed
- Response to sensed events
- Rate modulation
Describe position 1-chamber paced?
A(Atrium), V (Ventricle), D (Dual/both)
Describe position 2-chamber sensed?
A, V, D, O (if sensing is temporarily disabled)
Describe position 3- response to sensed events?
I – inhibits pulse in response to sensed event
T – triggers pulse in response to sensed event (no clinical purpose)
D – Pulses can be either inhibited or triggered
O – no response to sensed events
Describe position 4-rate modulation?
R – paced rate changes based on perceived physiological need
Describe VVI?
V Paced
V Sensed
I Response
Typical indications
AV block
Chronic Atrial Fibrillation
Not to be used with patients with normal sinus rhythm
Describe AAI?
A Paced
A Sensed
I Response
Sensing and pacing P waves
Typical indications
Sinus Node dysfunction without AV Block
This configuration doesn’t protect against AV node dysfunction worsening
If Heart block develops the pacemaker cannot help.
VDD (typical indications)?
V Paced
D Sensed
D Response
Typical indications
AV block without sinus node dysfunction
Describe DDD?
D Paced
D Sensed
D response
Both A + V leads sensed and paced
Typical Indication
Combination of Sinus node dysfunction and AV block in sinus rhythm
What are the seven different way a pacemaker can be programmed?
-Lower rate limit
-Upper rate limit
-AV delay
-Post-Ventricular atrial refractory period
-Sensitivity
-Output
-Mode switching
What is typical lower rate limit for a pacemaker?
50-60bpm
What is typical upper rate limit for a pacemaker?
120-130bpm
What is AV delay?
AV delay
Period of time pacemaker waits before pacing after sensing
150-200ms
What is PVARP?
Post-Ventricular atrial refractory period (PVARP)
Time after V depol during which an atrial impulse sensed by the atrial lead will be ignored for timing cycle purposes
Safety feature
250-300ms
What is sensitivity in pacemaker programming (and numbers)?
Sensitivity
Voltage a lead must measure in order to responds to an intrinsic depol
0.5mV Atrial lead
2mV for Ventricle lead
What is output for pacemaker programming?
Output
Voltage the pacemaker delivers to myocardium to initiate depol
1.5-2x capture threshold
What is mode switching in pacemaker programming?
Mode switching
Mode can automatically change with changes in heart rhythm
DDD –> VVI or DDI in Afib, Aflutter, or SVT
What are six implanted related pacemaker complications?
Implantation - Related
Pocket Hematoma
Pocket infection
Pneumothorax
Hemothorax
Lead dislodgement
Cardiac perforation/ tamponade
What are seven delayed pacemaker complications?
Delayed
-Electrode Lead Fracture
-Insulation Break
-Infection (pocket or lead causing Endocarditis)
-Thrombosis / stenosis
-Pacing induced cardiomyopathy
-Pacemaker Syndrome
(Palpitations, Chest pain, neck fullness)
-Pacemaker – mediated tachycardia
(Heart tissue recognizes paced rhythm as native causing stimulation of tissue.)
What are the contraindications to pacemakers (3)?
MRI (Modern Pacemakers are MRI compatible)
TENS units
Diathermy (surgery)
Pacemaker are okay with ____ and ____?
Ok with cellular phones and wearables
What should be done if a person with a pacemaker dies?
If Patient dies, Pacemaker should be removed prior to Cremation
The Crematory will blow up!
What are ICD’s?
Implantable Cardioverter-Defibrillators
What are ICD’s used for (What specific condition do they terminate)?
ICD’s used to terminate VT/VF in high risk patient
What do ICD’s contain?
Contain both pacing/sensing electrodes and 1-2 defibrillation electrodes/ coils
What are indications for ICD’s?
Secondary prevention of cardiac arrest or sustained VT in absence of completely reversible cause
Primary prevention of sudden cardiac death (SCD)
-Heart Failure + Ejection Fraction < 35%
-Post MI + Ejection Fraction <35%
-High risk pts with congenital Long QT syndrome, Channelopathies, Hypertrophic Cardiomyopathy
ICD’s also have an ____-____ ____ function?
ICD’s also have an anti-tachycardia pacing (ATP) function
How does an ICD’s prevent tachycardia?
-Attempts to stop reentrant VT
-Paces ventricles at rate slightly faster than VT
-ATP (anti-tachycardia pacing) is delivered in a burst of 8 paced impulses
-2 attempts before shocking
____ ____ ____ can occur from either RV pacing and/or from an underlying cardiomyopathy?
Symptomatic ventricular desynchrony can occur from either RV pacing and/or from an underlying cardiomyopathy
Specific way to restore synchrony to the heart from symptomatic ventricular desynchrony?
Insertion of an additional lead into the LV can restore synchrony
Referral for cardiac resynchronization therapy (CRT) based on what four things?
-LV EF
-QRS Width
-QRS morphology (LBBB vs other)
-New York Heart Association functional class (1-4)
What will placing a strong magnet over a pacemaker do?
Placing a strong magnet directly over a conventional pacemaker will switch its mode to asynchronous:
AAI –> AOO
VVI –> VOO
DDD –> DOO
What are indications for using a magnet on a pacemaker?
Indications
-Temporary use during electrocautery
-Termination of pacemaker-mediated tachycardia
What will placing a magnet on an ICD do?
Placing a strong magnet directly over an ICD will NOT switch its mode, but will instead turn off the defibrillation and anti-tachycardia pacing function
What are 3 indications for using a magnet on an ICD?
Indications
-Temporary use during electrocautery
-Repeated inappropriate shocks
-Patients on comfort care
