PACEMAKER ROTATION Practical Clinical Electrophysiology

Chapter 2: Cellular Electrophysiology All action potentials ARE NOT the same. Slow conduction (nodal tissue) different than fast conduction (His-Purkinje System, ventricular myocardium). Endo-, mid-, epicardial layers of ventricles have differences too. SA/AV nodes: Unique in absence of resting membrane potential. Rely largely on calcium channels with a slow upstroke. Do not depend on voltage-sensitive sodium channels to initiate depolarization. During diastole (repolarization), membrane potential drops to -50 to -60 before spontaneously depolarizing again. Starts with IF inward current (allows Na/Ca in, K out). IK1 also active, but shuts down during depolarization. Depolarization largely driven by slow voltage-gated inward calcium channels. There is a relatively SMALL amount of fast-acting sodium channels in nodal cells. On the downstroke its Ca out K in.

Atrial, HPS, Ventricular Myocytes: rapid activity due to sodium channels. Includes atrial & ventricular myocardium and entire conduction system except for the nodes. Phase 0: Sodium IN, fast. Phase 1: End of depolarization, Sodium OFF, Potassium OUT. Phase 2: Potassium OUT, Calcium IN at equal rate so plateau of mV Phase 3: Potassium OUT, Calcium OFF Phase 4: Baseline maintained by Potassium IN, Sodium OUT Myocardium stays at rest until stimulated (opening of Na channels) by current from pacemaker cells. Refractory period is time it takes for Na channels to recover which is upstroke to next baseline. Inward Na channel is main factor in

conduction velocity. Summary is: Na in, K out until baseline, Ca in at plateau

Baseline -90 to peak of 20+, ranges vary by textbook. Nodes -60 to slightly positive 5-10mV. Selected AP Alterations and Influence on EKG: Deviation of ST segment likely from voltage gradients between endoand epicardium. Notice the normal notch (spike and dome) from Phase 1 to 2. Notch is from Potassium OUT by I to. There is significantly more Ito in epicardial layers than endocardium and more in RV than LV. Difference creates a transmural voltage gradient manifested as J-point elevation. Sodium channel blockers and Potassium channel openers will decrease Phase 1 height (increase in net outward current) creating a voltage gradient making ST elevations. It is thought J point & ST elevation associated with early repole in bradycardia is caused by this lowered Phase 1 height. Depolarization and the QRS Interval: QRS represents ventricular depolarization so delays/blocks in bundle branches or ventricular myocardium will prolong it. Sodium blocking drugs (1C antiarrhythmic) may prolong QRS if heart rate is increased, but not at rest. Class 1A drugs may do it at rest because of a faster onset of binding. Remember, sodium channel is main factor in fast channel action potentials.

Repolarization and the QT Interval: QT interval is ventricular repolarization. Summarizes AP ion flow as Sodium & Calcium INWARD, Potassium OUTWARD. Chloride IN at Phase 1 but its ignored to simplify. Of course, at rest is Na/K pump (K in, Na out). Anything prolonging the AP will prolong the QT interval. Most QT prolongations are caused by decreases in Sodium IN or Potassium OUT. Blocks of Calcium IN will SHORTEN the AP duration.

Homework Module Definition: Retrograde AV conduction: depolarization from the ventricles to the atria Active Fixation lead: surgeon actively secures lead tip into tissue using a helix, corkscrew, or fish hook tip Pacemaker Syndrome: when only the ventricle is paced and it fires out of sync with atria, AV dyssynchrony. Cause is unknown, usually treated with addition of atrial lead or adjusting sensing, threshold, and AV delay values. Term is more for describing the symptoms related to AV firing out of sync. Acute Threshold: Threshold at time of implant, will be lowest ever, last about a week, then peaking phase until 6-8 weeks, ending with chronic threshold phase. Peaking is 3-4x higher than acute, while chronic is 2-3x higher than acute. Steroid coated lead tips greatly lower peak phase inflammation. Burst Pacing: used in AntiTachycardia Pacing (ATP) to eliminate reentrant circuit. A burst of stimuli, usually around 4 impulses, are fired at rate slightly faster than tachycardia hoping reentrant circuit hits cells during refractory period. Escape Interval: interval the pacemaker fires at after being reset by a natural or paced event. Easier to understand as VA interval meaning the A-A interval minus the AV interval. 60bpm = 1000msec between beats. With an AV interval of 200msec, the remaining 800msec is the Escape Interval or VA interval. Capture: threshold settings when pacemaker stimulus causes myocardium to contract Hysterisis: rate to initiate pacing is lower than pacing rate. Requires intrinsic rate to exceed pacing rate to shut off. Hysterisis at 60, LR at 70 mean pacing of 70bpm triggered by pulse under 60, until intrinsic exceeds 70. Cross-Talk: In dual chamber pacemakers, when paced events by either chamber are sensed as activity by other. Strength-Duration Curve: see Graph. Any pulse width/voltage combination above the curve will capture the heart.

The rheobase is the flat portion of curve giving no additional benefit to threshold. Chronaxie is 2x the rheobase. In this image, the physician has defined minimum settings they are comfortable with for safety. Cycle length: Interval between any two events measured in milliseconds. Divide into 60,000 to get heart rate. Demand Mode: fires whenever rate falls below lower rate limit, requires sensing NBG Codes: Pacing, Sensed, Response, Functions, AntiTachy Function Overdrive Pacing:pacing faster than tachycardia hoping tachy circuit hits cells during refractory period cancelling it out. Oversensing: sensing mV (amplitude) set too low causing inhibition of pacemaker activity. Usually set to about half of sensed amplitude.

Pacemaker-Mediated Tachycardia: ventricular activity RETROGRADE conducted to atria & sensed as atrial activity triggering a ventricular pace, creates a cycle. AS will likely appear during QRS of surface EKG. Fix by extending PVARP, switching to DVI, or applying magnet Rate Modulation: also Rate Responsive or Rate Adaptive. 4th NBG code. Piezoelectric crystal or other tools increase pacing rate when exercise is detected. Refractory Period: Time that pacemaker is programmed to ignore sensed activity. Duration usually covers QRS and T waves. Different from Interval. Sensing: ability to detect and analyze electrical activity Underdrive Pacing: Electrical stimulation of the heart at a rate lower than that of an existing tachycardia; designed to capture the
heart between beats, to interrupt a reentry pathway to terminate the tachycardia.

Pulse Width: also Pulse Duration. mSec duration of time the pacemaker is sending a signal. Voltage and Pulse Width are two settings available to control threshold. Sensing Threshold: Minimum stimulus needed to inhibit pacemaker Asynchronous Mode: pacing done without sensing, intrinsic rate is ignored Blanking Period: Interval where pacemaker ignores sensed activity during/after atrial or ventricular spike. *50-100 mSec. Exit Block: various definitions. Appears to refer to excessively high impedance due to scarring at lead tip preventing capture After Potential: electrolytes of opposite charge migrate towards lead tips during impulse discharge. This buildup of ions can be sensed as they diffuse to their neutral areas afterwards. Polarization Resistance: As listed above, ions around lead tip and rings move toward their opposing charge. (+) ions move toward cathode (-) & (-) ions move toward anode (+). Resistance (impedance) rises as ions cluster around poles. PBL STOP PRESENTATION: look at EKG for loss of capture, fused/pseudobeats. Current mode (DDD, VVI.....) and LR. What is pts current pulse? Sensitivity and output settings, previous threshold tests, notes from Tech/Doctor Model #, % of time AP and VP BATTERY: Voltage & Impedance (IPG) Beginning Of Life, ERI time Voltage & Charge Time (ICD) Pacing Lead = 200 to 2000 Ohms ICD shocking lead(HV) 35-55 Ohms Compare values to past impedance trending: >20% +/- is significant lower LR to allow intrinsic rhythm to show, may need to increase AV Delay measure sensed P (1.0-2.5mV) and R (>5mV) waves PROGRAM sensitivity to less than of sensed P (0.25-0.5mV) & R (2.0-4.0mV) overdrive the rate (20+ intrinsic) to ensure fully paced, then decrement energy down until loss of ATRIAL: longer AV Delay: 200-250 msec VENTRICLES: shorter AV Delay: 100 msec

LEADS:

SENSING:

THRESHOLD: capture.

ATRIAL P waves too small to see? Use AAI and watch for QRS loss, but pt. cant have Heart Block *If HB, you have to use DDD. !!! Safety margin for amplitude (mV) is 2x sensed value or 3x for pulse width!!! OBSERVATIONS/PARAMETERS: Review high rate/mode switch episodes (review internal EGMs & Histograms) Print test results, histograms, and final report

MODULE 2: FUNDAMENTALS OF CARDIAC DEVICES Devices can perform diagnostics on Patient and Device: Device: lead impedances, pacing thresholds, sensing, battery voltage and remaining life Patient: AF burden, activity levels, % AP & VP, Heart rate trends, even fluid accumulation IPG: Implantable Pulse Generator. 8-10 year longevity ICD: Implantable Cardioverter Defibrillator. Can defibrilate, cardiovert, possibly Anti-Tachy Pace (ATP) 6-9 years life Medtronic MVP feature: Managed Ventricular Pacing. AAIR, will switch to DDDR if ventricle stops following AP. Website says DDD and Vpacing in general greatly increases HF and Afib risks. In general, we want to pace the ventricles as little as possible because it leads to ventricular dyssynchrony. CRT: Cardiac Resynchronization Therapy. Usual RV lead plus an LV lead placed on the posterior-lateral wall via the coronary sinus. If unable to use CS, lead may be sutured externally to LV. High Power has ICD, Low Power does not. ILR: Implantable Loop Recorder. For recurrent syncope. Pt. can trigger when symptomatic. Indications for Pacemaker: refractory symptomatic bradycardia, Sinus Node Disease, Sick Sinus Syndrome, Complete Heart Block, Chonotropic Incompetence, Vaso-vagal syncope. SND w/o HB= pace atrium, Afib with slow ventricles= pace ventricle. Usually both chambers get leads. Indications for ICD: Primary prevention is implant for at risk of sudden cardiac arrest (SCA), Secondary is after SCA or ventricular arrhythmia. Initially done after 2 SCD events. Improved devices/surgery expanded indications: MI due to VT/VF, Syncope with VT/VF, nonsustained VT w/CAD, any VT refractory to drugs CLASS I indications for ICD(AHA): 40 days post-MI (EF <40%, NYHA class II/III), nonischemic (EF<35%, class II/III), congential disorders (Long QT, Brugada, HCM, Arrhythmogenic Right Ventricular Dysplasia) CRT Indications: NYHA Class III/IV, max medications, QRS >120ms, EF<35%, best for systolic HF XRAY device recognition: RA lead in RA appendage, RV lead in apex. Shocking coils in ICD leads are thicker. CRT will have 3 leads. CRT high/low power recognized by ICD coils. Always check medical records as old leads are sometimes left in patient. Biphasic ICD: both defib/cardiovert delivered in biphasic waves. Common pattern is from SVC + can to RV, and back in reverse. CRT benefits: dyssynchrony of ventricles lowers EF, septum sways, and MR is noted. CRT improves EF and symptoms. Warnings/Precautions: ICD/CRT not for brady rhythms, disease/medications may change function, avoid magnets, CRT enters VVI @65bpm at ERI, if external paddles used for defib avoid placing pad on pacemaker. Dont pass RV lead through TV if its diseased or artificial. Dont suture epicardial leads on infarcted/fibrotic myocardium. Avoid diathermy (ultrasound waves used to deliver heat in physical therapy). MODULE 8: PACEMAKER PATIENT FOLLOW UP Thresholds: Combination of Pulse Width and Voltage. Safety margin rules once you find threshold are: double the threshold when programming or leave the threshold and triple the pulse width. How to manually test Pacing Threshold: Atrial: Using AAI on a patient with AV conduction, increase the pacing rate to above the intrinsic rate Atrial: Using DDD on a patient without AV conduction, increase the pacing rate to above the intrinsic rate Ventricular: Using VVI, increase the pacing rate to above the intrinsic rate

Ventricular: Using DDD, decrease the AV to below the intrinsic AV interval After Sensing and Threshold interrogation, ALWAYS check the rate HISTOGRAMS. Rates below LR may be timing anomalies and rates above UTR may be arrhythmias. ALWAYS check OBSERVATIONS for arrhythmias and ASK THE PATIENT about events and symptoms. Physician may change anticoagulant meds for Afib risk of stroke. Check EGMS (ECGs recorded by pacer leads) for detail of reported arrhythmias as machine Dx may be wrong. What is the VP% goal for a CRT? 100% Search AV: Medtronic feature to reduce VP%. AV interval monitored and extended if >50% VP. Results in 40-50%VP. ELECTROPHYSIOLOGY STUDY POWERPOINT Pace the atrium and stop. Sinus Node Recovery Time (SNRT) is the time interval from last paced atrial beat to first intrinsic atrial beat. Normal is < 1.3 x SCL (<1600). Corrected SNRT (CSNRT) is SNRT SCL (<525). To evaluate AV node, time interval is measured from Atrium to His Bundle. His Bundle deflection can only be viewed in His leads during EP study. AV node is between SA node & His Bundle, so time changes of interval indicate AV node function. Atrium is paced at gradually increasing rates. AHi increases as AVN cant keep up with atrium. When AVN drops a beat is the AVN Wenckebach cycle length. Refractory periods, conduction changes, dual AV node physiology, and arrhythmias can be detected by a train of 8 atrial beats with an extra 1,2,or 3 extra stimuli. Same thing done in RVA. Incremental Ventricular Pacing to examine retrograde AVN function. Pace RVA at increasing rates. Monitor for VA interval increases. Concentric activation (via AV node) is when Atrial deflection seen in His before HRA indicating normal pathway, Eccentric activation (via AP) is seen in CS before His or HRA indicating pathway through LV across LA into RA. Determine VA wenkebach CL. PRi (120-200), QRS(<100), QTc(<440), AHi (60-125), HVi (35-55ms)

Brugada Syndrome: Increased risk of SCD from Vfib. Gene mutation in ion channels. ICD is treatment. Study leads V1-V3 for ST elevation and a RBBB appearance. 3 variations. Possible m shaped or saddleback ST elevation. WPW: short PRI into delta wave and wide QRS. Delta wave is slurred, curved upstroke into R wave. Classified as a pre-excitation syndrome. Bundle of Kent is accessory pathway allowing premature stimulation of ventricles. Pathway lacks AVN slowing of impulses resulting in extra and faster ventricular rates. This faster impulse is manifested as the delta wave. Pathways located in AV valve rings.

AVNRT: SVT so it comes from above His Bundle. Most common type of SVT, main symptom is palpitations. Vagal move, meds, cardioversion. Frequent cases can be ablated. Reentry circuit forms within or next to AVN in two channels in Right Atrium, fast & slow. EP tools: Programmable Stimulator: pacing output 0.1-10mA provides the pacing impulses to heart Multichannel Physiologic Recorder: program records intracardiagram and EKG Intracardiac Electrode Catheters: used to deliver impulses and measure electricity at several locations Afib Pacemaker: Better results with controlling the Afib rate compared to trying to stop the Afib. Leave the patient in Afib, give BB/CBB to slow the rate, and possibly ablation of the AVN. Pacemaker needed to control ventricles after ablation. Effective/Absolute Refractory Period: new potential cannot be initiated. Functional Refractory Period: minimum interval possible between depolarizations. Determines max rate. Catheters in EP: HRA CS His RVA PA: P wave of surface to A wave of HBE. (20-50ms), longer indicates atrial enlargement AH: study of AVN, measured A to H on HBE (45-140ms), longer in AV node disease HV: proximal His to Ventricles. Earliest His in HBE to QRS in V1/V2. (35-55ms), longer for BBB HBE: 90% of defects found in HBE, His Bundle bi/triphasic (15-25ms) between A & V spikes AAO / VOO / DOO: fixed rate VVI / AAI: demand VAT: AS triggers VP DDD: physiologic pacemaker, rate responsive as long as atrial rate increases with exercise DVI / VDD / DDD: AV sequential