Beruflich Dokumente
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Implantable Cardioverter
Defibrillators
Dr. Sivaraman Yegya-Raman
Permanent Pacing
Lead
Pacemaker
Pacemaker Implantation
Transvenous :
Generator implanted anterior to pectoral muscle
Atrial/Ventricular leads via subclavian or cephalic
vein
Sensing and pacing threshold
Chest X-ray for pneumothorax, lead position
Castle LW, Cook S: Pacemaker radiography. In Ellenbogen KA, Kay GN, Wilkoff BL [eds]: Clinical Cardiac Pacing. Philadelphia, WB Saunders, 1995, p 538.
Pneumothorax, hemothorax
Air embolism
Perforation of central vein
Inadvertent arterial entry
Lead placement
Brady tachyarrhythmia
Perforation of heart, vein
Damage to heart valve
Generator
Pocket hematoma
Improper or inadequate connection of lead
Lead-related
Thrombosis/embolization
SVC obstruction
Lead dislodgement
Infection
Lead failure
Perforation, pericarditis
Generator-related
Pain
Erosion, infection
Migration
Damage from radiation, electric shock
Patient-related
Twiddler syndrome
Specific
Designati
ons
O=none
A=Atrium
V=Ventric
le
D=DualAtrium
and
Ventricle
O=none
A=Atrium
V=Ventricl
e
D=DualAtrium and
Ventricle
O=none
T=Trigger
ed
I=Inhibite
d
D=DualTriggered
and
Inhibited
Multisit
Modulati e
on
pacing
O=none
R=Rate
modulation
O=none
A=Atrium
V=Ventri
cle
D=DualAtrium
and
Ventricle
NASPE/BPEG 2002
DDD
Degree
Pacemaker necessary
Third
Symptomatic congenital
complete heart block
Aquired symptomatic complete
heart block
Atrial fibrillation with complete
heart block
Acquired asymptomatic
complete heart block
Second
Symptomatic type I
Symptomatic type II
First
Pacemaker
probably
necessary
Pacemaker not
necessary
Asymptomatic
Asymptomatic type
type II
I at supra-His (AV
nodal) block
Asymptomatic
type I at intra-His
or infra-His levels
Asymptomatic or
symptomatic
Symptomatic bradycardia
Symptomatic patients
with sinus node
dysfunction with
documented rates of <40
bpm without a clear-cut
association between
significant symptoms and
the bradycardia
Symptomatic sinus
bradycardia due to longterm drug therapy of a
type and dose for which
there is no accepted
alternative
Case #1
72 year old male with chronic atrial
fibrillation of greater than 10 years
duration is admitted following a
syncopal episode. A 2D echo shows
LVEF 60%. Telemetry reveals atrial
fibrillation with slow ventricular
response and pauses of 5 to 6 seconds
associated with lightheadedness.
How would you proceed?
Case #1
72 year old male with chronic atrial
fibrillation of greater than 10 years
duration is admitted following a syncopal
episode. A 2D echo shows markedly dilated
left atrium and LVEF 60%. Telemetry
reveals atrial fibrillation with slow
ventricular response and pauses of 5 to 6
seconds associated with near syncope.
How would you proceed?
Answer: Implant a ventricular rate
responsive pacemaker
Pacemaker Follow-up
GOAL OF FOLLOW-UP
Verify appropriate pacemaker operation
Optimize pacemaker functions
Document findings, changes and final
settings in order to provide appropriate
patient management
Pacemaker Syndrome
Fatigue, dizziness, hypotension
Caused by pacing the ventricle asynchronously,
resulting in AV dissociation or VA conduction
Mechanism: atrial contraction against a closed
AV valve and release of atrial natriuretic
peptide
Worsened by increasing the ventricular pacing
rate, relieved by lowering the pacing rate or
upgrading to dual chamber system
Therapy with fludrocortisone/volume expansion
NOT helpful
Sources of Electromagnetic
Interference
Medical
MRI
Lithotripsy
Electrocautery/cryos
urgery
External
defibrillators
Therapeutic
radiation
Nonmedical
Arc welding
equipment
Automobile engines
Radar Transmitters
Biventricular Pacing
Normal Conduction Is
Important
Sinus
node
AV
node
Normal conduction
allows for prompt
and synchronous
activation of the
atria and ventricles
Results in a brief P
wave, PR interval
and a narrow QRS
AV
node
Conduction
block
Heart Failure
Bifocal Ventricular Pacing
Sinus
node
AV
node
Conduction
block
Intraventricular
Activation
Organized
ventricular
activation
sequence
Coordinated septal
and free-wall
contraction
Stimulation Improved pumping
therapy
efficiency
Bi-Ventricular Pacing
Right atrial lead
SVC coil
RA lead
LV lead
RV coil
RA lead
LV lead
RV lead
Bi-V Pace
Implantable Cardioverter
Defibrillator (ICD)
ICD Implantation
Secondary prevention: Prevention of
SCD in patients with prior VF or
sustained VT.
Primary prevention: Prevention of
SCD in individuals without a h/o VF or
sustained VT.
Ellenbogen K A, 2007
ACC/AHA/HRS 2008 Guidelines: Systolic Heart Failure Cardiac Resynchronization Therapy (CRT)
Recommendations
LVEF 35%
QRS 120 msec
NYHA functional Class III or
ambulatory Class IV
Optimal medical therapy
Typical Case
58 year old male, CAD, prior MI, EF 28%, CHF,
NYHA class II, Medications: Furosemide 40 mg,
Enalapril 20 BID, Aldactone 25 qd, Carvedilol 25
BID, no syncope or VT, ECG: Sinus rhythm, old
anteroseptal MI, QRS 92 msec
Based on available trial data, you would suggest:
A. Treating medically without device
implantation
B. Implanting an ICD
C. Implanting an ICD with biventricular pacing
capabilities (3 leads)
Typical Case
Q: 60 year old female presents with
ICD
BiV ICD
Magnet Application on
Pacemaker/ICD
Pacemaker:
Disables sensing
Changes to VOO or DOO mode
Useful if cautery is being used in PPM dependent pt.
ICD:
Disables Tachycardia sensing
Useful at bedside if pt. has ventricular lead fracture
or Afib with rapid ventricular response causing ICD
shocks
Prevents ICD shock during cautery application at
surgery
Future Directions
Leadless pacing
Biological pacemakers
Subcutaneous ICD