Pacemakers

Indications for permanent

pacemaker therapy

Sinus node dysfunction

Sick sinus syndrome
Third degree heart block
Fibrosis or sclerotic
changes in the
conducting system
Tachyarrhythmias
Chronic Atrial
Fibrillation with slow
ventricular response.
Heart Failure

A pacemaker is a battery powered,

electronic device used to stimulate
the heart to depolarize and contract.
Usually named according to where
the electrodes are located and the
route the electrical current takes to
the heart

A pacemaker consist of a (1)

generator (battery) which creates
the electrical stimulus: (2) a
connector where the leads attach:
and, (3) one or two lead wires that
carry the signals to the heart
muscle.

Pacing may be permanent or

temporary.
Temporary pacer

Located externally transvenous,

epicardial, or transcutaneous

Transvenous

Stimulates the endocardium of the

right atrium or ventricle by means of
electrode into central vein
(subclavian or cephalic vein)

Uses for Temp Pacer

Cath, angioplasty, CABG,
eletrophysiological studies
MI
Tachyarrhythmias

Epicardial implantation

Takes longer and

requires more
recovery time. A
opening is made in the
lower chest and the
lead is threaded up to
the outside of the
heart. The generator
is attached to the
leads and placed
underneath the skin in
the abdomen.

Transcutaneous

Pads are placed on the anterior and posterior chest wall

Pads have a connecting cable that is attached to a bed side
Zoll/Pacer Defibrillation machine
Used for Quick , bedside emergent needs for pacing- not long
term patients unresponsive to atropine
Once pads are on patient This is done until capture, then
rate is dialed up to 30-125 BPM
Energy level is selected with MA (milliamps) 25-50 mA
usually upper limits 82 mA
May need to provide sedation for patient- related to feeling of
pacing
Also oxygen, IV access, and EKG monitoring

Implanting the
Pacemaker

Typically done in the OR or Cath Lab under local

anesthesia. An incision is made into the skin just under
the clavicle and a small pocket it is created . The lead
wires are threaded through the incision into the
subclavian (transvenous) to the heart. The leads are
attached to the generator and the generator placed in
the subcu pocket. The pacemaker is then programmed.

Care of Pacer

Location of right or left is determined by

hobbies, occupation, or patients
handedness
Prevent Infection- usually keep clean and
dry, if instructed to wash use antibacterial
soap and water, pat dry
Avoid lotions, creams, or powders
Avoid hyperextension of arm (allows for
leads to secure)
Avoid straps- bras, seatbelts, avoid driving

Care after Pacer

Bed rest for few hours related to

sedation
Cardiac monitor- to be sure the
pacer is functioning
Prophylactic antibiotic

Teaching

For at least one week

Patient may return to daily activities but take it easy (no
heavy lifting, running, contact sports).
The arm on the operative side should not be raised over
the head.
Dont hit or rub the insertion site.
Patient should take his temp and inspect the site for signs
of infection.
Stitches out in 1 -2 weeks. Return to work in 1 2 weeks.

Risks/Complications

Bleeding or hematoma
Tearing of the vein or artery wall
Thrombus
Embolus
Puncture of the lung or heart muscle
Nerve damage
Infection
Pacemaker malfunction

Single chamber

Dual chamber

Coding

A 3 letter code has been developed to

describe the various pacemakers.
First letter -- the chamber paced:
V(ventricle), A(atrium), or D(dual or double).
Second letter -- chamber sensed:
V(ventricle), A(atrium), D(double), or 0
(none).
Third letter mode of response to sensing:
T(triggered), I(inhibited), or D(double).
SoVVI means that the ventricle is paced,
the ventricle is sensed, and the pacer is
inhibited by a sensed beat.

Third Letter

3rd position - I (inhibited), the mode of response is to

withhold a pacemaker output in the presence of a
sensed event- patients event. In a VVI pacemaker,
the pacemaker senses a ventricular event and
withholds the ventricular output. If the pacemaker is
programmed to the DDI mode, the pacemaker
simply inhibits the output of the device in the
chamber where any signal is sensed. In the presence
of fast atrial rates and heart block, the DDI
pacemaker rhythm resembles a VVI pacemaker.

The letter D (dual) in the third position indicates that

the device will respond to the sensed signal by either
inhibiting the pacemaker response, tracking the sensed
event, or inhibiting the output on the sensed channel
and triggering an output to maintain AV synchrony. The
most common example of the letter D in the 3rd
position can be seen with DDD pacemakers. A sensed
atrial signal will cause the device to inhibit the atrial
output, a timer then starts that will cause a triggered
ventricular output after a certain interval. If the patient
has an intrinsic R wave during the triggering interval,
the pacemaker will inhibit the ventricular output.

Modes of Pacing

Demand- (Synchronous) PM that

discharges only when patient s heart
rate drops below the preset rate
Fixed rate- (Asynchronous)
pacemaker- PM that continuously
discharges at present rate regardless
of the patients intrinsic activity
Rate adaptive- changes with activity

Checking the Pacemaker

Routine office
visits with EKG

Pacemaker can be
checked from
home

From time to time

the pacemaker
settings may need
to be adjusted

Teaching contd

Carry an ID card and show it to any doctor, dentist, etc

that you see. Also may need to present to security
personnel (airport, library, department store).
Exercise regularly ( swimming, biking, jogging)avoid
activities like racquetball and contact sports.
Modern pacemakers are well protected from outside
signal. Microwaves, hairdryers, power tools,
computers, TV, radio, electric blankets, heating pads
are OK.
Avoid very strong magnets such MRI, heavy duty
electrical equipment, ham radios, radio transmitting
towers.
Cell phones may cause problems. Hold them to the ear
opposite the pacemaker.

Cardiac Resynchronization
Therapy (CRT)

Both ventricles (biventricular) are

paced to resynchronize the cardiac
cycle resulting in improved cardiac
function.

Ventricular Pacing

Ventricular pacing

V Pacing

AV Pacing

Pacemaker Malfunction

Failure to sense (pacer lead fracture,

battery failure, movement of the electrode)
PM fails to recognize spontaneous
myocardial depolarization
Failure to capture (pacer lead fracture,
battery failure, movement of the electrode,
fibrosis at the catheter tip) inability of
pacer to depolarize the myocardium
Failure to Pace- (failure to fire)- failure to
procedure an electrical stimulus or impulse
when needed or correct number of impulse

Failure to sense

PM fails to recognize spontaneous

myocardial depolarization

Failure to Capture

Inability of pacer to depolarize the

myocardium

Failure to pace (Fire)

failure to procedure an electrical

stimulus or impulse when needed or
correct number of impulse

Troubleshoot New or
temporary pacemaker

Failure to Sense
Failure to Capture