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Introduction Indications Pacemaker system (components) Insertion Settings Codes Temporary pacing modes Malfunction and troubleshooting Patients


Cardiac Pacemaker

A pacemaker system is a device capable of generating artificial pacing impulses and delivering them to the heart. It consists of a pulse generator and appropriate electrodes. In the past few years electronic pacemaker systems have become extremely important in saving and sustaining the lives of cardiac patients whose normal pacing function of the heart have been impaired.

Why need the pacemakers?

Sometimes a heart's natural rhythm is interrupted or becomes irregular- bradycardia
The heart's natural pacemaker sends out electrical impulses too slowly due to a diseased SA node. Or, the electrical impulses may be blocked along the pathway through the heart, -"heart block." Symptoms: dizziness, extreme fatigue, shortness of breath, or fainting spells.

A pacemaker stimulates the heart muscle with precisely timed discharges of electricity that cause the heart to beat in a manner very similar to a naturally occurring heart rhythm.

Conduction disorders
2nd and 3rd degree heart block

Rate disorders
Asystole Symptomatic sinus bradycardia Sick sinus syndrome

Post cardiac surgery Back up

1st Degree Block

every beat coming from the atrium is transmitted to the ventricles, but they take longer than normal to travel through the AV node. prolonged P-R interval (>0.2 sec) indicates delayed AV conduction, but all impulses get through. Usually asymptomatic. Thus, there is a prolonged PR interval (>200 msec)

2nd Degree Block Mobitz Type I (Wenckebach)

in this condition there is a gradual prolongation of the PR interval followed by a dropped beat (P wave not followed by a QRS complex). Classically, the RR interval becomes shorter between beats, because the longest increment in the PR interval occurs between the first and second conducted P waves.

Generally associated with a lesion above the bundle of His.


2nd Degree Block Mobitz type II

in this condition there are regular PR intervals with intermittent dropped P waves which follow no particular pattern. This tends to be related to pathology below the bundle of His, and has a worse prognosis with regard to progression to complete heart block

3rd degree AV block

none of the atrial beats are conducted to the ventricles. In this condition the P waves are regular and the QRS complexes are regular, but each occurs at a separate, unrelated rate. The ventricular rate represents an escape rhythm and usually has a rate of 30 to 40 bpm. The QRS complexes are wide because they arise in one ventricle and are conducted to the contra lateral ventricle by cell to cell spread of the electrical activation. Affected people experience periods of: syncope, dizziness, fatigue, exercise intolerance or episodes of acute heart failure. Treated with a permanent cardiac pacemaker.

Bundle Branch Block

Lack of impulse getting through either L or R branch. Ventricles depolarizing one after the other. Leads to ventricles contracting out of unison. On ECG QRS is wider (normal 0.08 0.12 sec)

Components of the Pacemaker

Pulse generator Pacing leads
External Epicardial Transthoracic Transvenous

Pacing system
Unipolar Bipolar



Bipolar Tip of the Lead Wire


External: in emergency at the bedside

Epicardial: inserted during surgery

Atrial: exit chest wall to the Rt. Of sternum Ventricular: exit chest wall to the Lt. Of sternum Transthoracic: last resort during emergencies Transvenous: Inserted under fluoroscopy through subclavian or jugular vein

Components of bipolar temporary Transvenous pacing system


Setting Parameters
Rate Sensitivity threshold Stimulation threshold (output)


Setting Parameters
Fixed: stimulus provided at a preset rate (grater than patients rate) Demand: stimulus provided when the patients heart falls below a predetermined rate (proper sensing is required)


Setting Parameters
Sensitivity threshold:
regulates the ability of the pacemaker to detect the hearts intrinsic electrical activity (senses R wave) Measured in mV Sense indicator flashes when sensing inherent patients signal Sensitivity set 2-3 times (or half) lower than Sense indicator Threshold

Setting Parameters
Stimulation threshold (output)

The electrical current that is delivered to the heart to initiate depolarization It is measured in milliampers (mA) Threshold: the point at which depolarization occurs and identified by a myocardial response to pacing (capture) Set to double the minimum amount of mA needed to achieve 100% capture

Pacemaker Modes and Codes

Three-letter codes for temporary pacemakers Five-letter codes for permanent pacemakers
Programmability Antitachydysrhythmia function (ICD)


Three-letter codes for temporary pacers

I Chamber paced II Chamber sensed 0=None A=Atrium III Response to sensing 0=None T=Triggered

0=None A=Atrium

D=Dual (A+V)

D=Dual (A+V)

D=Dual (T+I)

Pacemaker Modes and Codes

Fixed-rate (asynchronous) pacing
Delivers pacing stimulus at a fixed rate regardless of spontaneous cardiac depolarization (nonsensing)

Demand (synchronous) pacing

Delivers pacing stimulus when the hearts intrinsic pacing fails below a predetermind rate. Pacing is either inhibited or triggered by the sensing of intrinsic beats

Atrioventricular (AV sequential) pacing

Delivers pacing stimulus to atrium and ventricle in physiological sequence with sufficient AV delay.

Examples of Pacing Modes

Fixed rate A00 Atrial pacing, no sensing, no inhibition or trigerring V00 Ventricular pacing, no sensing, no inhibition or trigerring D00 Atrial & Ventricular pacing, no sensing, no inhibition or trigerring Demand AAI Atrial pacing, atrial sensing, inhibition response to P wave VVI Ventricular pacing & sensing, inhibition response to QRS DVI Atrial & Ventricular pacing, ventricular sensing, inhibition for both by intrinsic ventricular depolarization

Universal (Dual) DDD Atrial & Ventricular pacing & sensing, inhibition for both intrinsic P & QRS, triggered response to sensed P wave to allow for rate responsive ventricular pacing

ECG Strip of 100% Ventricular Pacing


Pacing srtips
A: atrial pacing

B: Ventricular pacing

C: Dual chamber pacing


Malfunction and troubleshooting

Failure to Capture Failure to Fire (Failure to pace) Undersensing Oversensing


Failure to Fire
Spikes are not noted during period of asystole or bradycardia Causes
Loose connection son the system Failure of battery or pulse generator Broken lead wires Lead wire dislodgment Assure pacing connections Replace battery or generator as appropriate Reposition leading wire Attempt pacing with another pacing system


Failure to Fire


Failure to Capture
Spike is not followed by a P or QRS complex as appropriate Causes
Loose connections on the system Failure of battery or pulse generator Broken lead wires Lead wire dislodgment or fibrous at site of electrodes low pacing threshold (output)

Assure pacing connections Check threshold and increase output mAm Repositioning the patient may also resolve the problem

Failure to Capture


Failure to capture


Failure to pace Effect of patients psition


Inability of the pacemaker to sense spontaneous myocardial depolarization Pacemaker looses its ability for self-inhibition Competition between the paced complexes and intrinsic hearts rhythm occur Demonstrated on the ECG by a pacing spike occurring after or unrelated to intrinsic QRSs It is a serious malfunction that could lead to dangerous ventricular dysrhythmia as VT & VF

Inadequate QRS signal (QRS signal not detected by pacemaker, low sensitivity) Myocardial ischemia, fibrosis, electrolytes disturbances Inappropriate mode selection (asynchronous)

Increase sensitivity (moving the sensitivity dial toward its lowest setting)


Undersensing. This transcutaneous temporary pacemaker set in the ventricular demand mode fires and paces appropriately in the beginning of the strip. The 9th complex is the patients inherent QRS complex which should have been sensed by the pacemaker. Instead the pacemaker fired.



Inappropriate sensing of patients QRS The pacemaker thinks it detects a QRS complex so it inhibit itself and does not fire Result in unexplained pauses in the ECG traces Causes
Tall P or T waves Electrical signals produced by skeletal muscle contractions (during shivering or seizures) EMI

Decrease sensitivity (moving the sensitivity dial toward its highest setting, 20 mV) Place a magnet over the generator to restore pacing (in permanent pacemakers only)





Patients Management
ECG monitoring Hemodynamic monitoring Frequent assessment of pacemaker Electrical safety Pacing insertion site care
Cleaning, dressing, signs of infection

Protect pacemaker from accidental adjustment Patient & family education