Cardiology for Dr.

Pelaez By Sai Kumar Reddy

American International Medical University, St.Lucia

Pacemaker
A pacemaker is a battery-powered device about the size of a pocket watch that sends weak electrical impulses to set a pace so that the heart is able to maintain a regular heartbeat.

Anatomy & Physiology of Pacemaker

Types of Pacemakers
Single-chamber pacemakers stimulate one chamber of the heart, either an atrium or more often a ventricle. Dual-chamber pacemakers send electrical impulses to both the atrium and the ventricle and pace both chambers. A dual-chamber pacemaker synchronizes the rhythm of the atria and ventricles in a pattern that closely resembles the natural heartbeat.

Indications for Pacemaker

Absolute indications
Sick sinus syndrome Symptomatic sinus bradycardia Tachy-brady syndrome Afib with slow ventricular response 3rd degree heart block Chronotropic incompetence
Inability to increase heart rate to match exercise

Prolonged QT syndrome

I
Relative indications are: Cardiomyopathy
Dilated Hypertrophic

Severe refractory neurocardiogenic syncope Paroxysmal atrial fibrillation

Pacemaker defects
EKG abnormalities due to
Failure to output Failure to capture Sensing abnormalities Operative failures

Pacemaker Failure to Output

Definition
No pacing spike present despite indication to pace

Etiology
Battery failure, lead fracture, break in lead insulation, oversensing, poor lead connection.
Atrial output is sensed by ventricular lead

Pacemaker Failure to Capture

Definition
Pacing spike is not followed by either an atrial or ventricular complex

Etiology
Lead fracture or dislodgement, break in lead insulation, elevated pacing threshold, MI at lead tip, drugs, metabolic abnormalities, cardiac perforation, poor lead connection

Pacemaker Sensing Abnormalities

Oversensing
Senses noncardiac electrical activity and is inhibited from correctly pacing Etiology
Muscular activity (diaphragm or pecs), EMI, cell phone held within 10cm of pulse generator

Undersensing
Incorrectly misses intrinsic depolarization and paces Etiology
Poor lead positioning, lead dislodgement, magnet application, low battery states, MI

Pacemaker Complications
Pacemaker syndrome
Patient feels worse after pacemaker placement Presents with progressive worsening of CHF symptoms Due to loss of atrioventricular synchrony, pathway now reversed and ventricular origin of beat

Pacemaker Operative Failures

Due to pacemaker placement
Pneumothorax Pericarditis Perforated atrium or ventricle Dislodgement of leads Infection or erosion of pacemaker pocket Infective endocarditis (rare) Venous thrombosis

Electromagnetic Interference
Can interfere with function of pacemaker Device misinterprets the EMI causing
Rate alteration Sensing abnormalities Asynchronous pacing Noise reversion Reprogramming

Electromagnetic Interference
Examples
Metal detectors Cell phones High voltage power lines Some home appliances (microwave)

Caution
If you have a pacemaker, you are not supposed to have an MRI (magnetic resonance imaging) test.

Advancement of Technology in Medicine

Newer pacemakers also can monitor your blood temperature, breathing, and other factors and adjust your heart rate to changes in your activity.

Case
CC: Chills, rigors HPI:
65 yom c/o fevers, chills, rigors x 1 day. Positive n/v and anorexia. Pt states he had recent pacemaker insertion 4 days ago for an arrhythmia.

PMH:
HTN Arrythmia Hypercholesterolemia

PSHx:
As stated above

Case
Physical exam
Temp 101.2, HR 110, BP 90/55 EKG

Diagnosis?

Case
Pocket Infection Pacemaker insertion is a surgical procedure
1% risk for bacteremia 2% risk for pocket infection

Usually occurs within 7 days of pacemaker insertion May have tenderness and redness over pacemaker site

References
Emedicine http://www.emedicine.com/emerg/topic805.htm Minish, Travis. Pacemaker Emergencies. http://www.cgi.ualberta.ca/emergency/rounds/files/pacers3.ppt The Implantable Pacemaker, a short historical overview.
http://igitur-archive.library.uu.nl/dissertations/2006-0426-200006/c1.pdf

Healthy Hearts
http://www.healthyhearts.com/pacemaker.htm

Medtronic
http://www.medtronic.com/patients/heart.html

Shelton State University

http://www.sheltonstate.edu/userfiles/File/faculty/s%20warren/NUR%20202%20EKG% 20Dysrrhythmias-Sinus,%20Atrial,%20Junctional,%20Vent%20.pdf

Google Images
http://images.google.com