PERMANENT PACEMAKER

Yanna Indrayana
 EVOLUTION
Last generations
Smaller, last
longer, MRI
Late 1920s compatible, self
1958
early 1930s 1990s adjustment,
First 1970s
First external Microprocessor- internal
pacemaker Passive and active
cardiac pacemaker driven pacemaker defibbrilator
implantation fixation

1957 Mid 1960s

1980s 2000s
First battery- Transvenous
Steroid-eluting Bi-ventricular
operated wearable leads
leads pacing
pacemaker replacement
Pacemaker System
Pulse Generator Pacing Lead

Right Atrium

Right Ventricle
The Pulse Generator
Contains a battery to
provide energy for sending
electrical impulses to the Connector
heart Block
Houses the circuitry that Circuitry
controls pacemaker
operations
Battery
Includes a connector to
join the pulse generator to
the lead(s)
 Leads

Insulated Wires
Deliver electrical impulses Lead

from the pulse generator to

the heart
Sense cardiac depolarization
 Passive Fixation Leads

Passive Fixation Passive Fixation

tines wings
 Active Fixation Leads

The helix, or screw,

extends into the
endocardial tissue
Allows for lead positioning
anywhere in the hearts Active Fixation
chamber screw-in
The helix is extended using
an included tool
Epicardial Leads

Leads applied directly to

the surface of the heart
Fixation mechanisms
include:
Epicardial stab-in
Myocardial screw-in
Suture-on
Applied via sternotomy or
laproscopy
Single Chamber Pacing
Atrial Pacing Ventricular Pacing

+ Implantation of a single lead

Single atrial pacing does not provide ventricular backup if A-to-V

-
conduction is lost
Single ventricular pacing does not provide AV synchrony
Dual Chamber Pacing

AV synchrony

+ Reduce heart failure occurrence, atrial fibrillation, stroke risk

and mortality increase quality of life
High cost

- High skill
 The pacing stimulus
The pacemaker delivers the electrical current between two points, called electrodes.
UNIPOLAR BIPOLAR
Anode
+

Anode
+

When pacing, the impulse stimulates large area of
the body between the tip of the lead and the pulse
generator
Usually exhibit larger pacing artifacts on the surface
ECG
When pacing, the impulse flows through the tip electrode
located at the end of the lead wire
Pacing artifacts may be very difficult to see on the surface
ECG
May have a larger diameter lead body than unipolar leads
Electrical Concepts

Voltage : the force or push that causes electrons to move

through a circuit.
Measured in volts (letter V), often referred to as amplitude

Current : flow of electrons in a completed circuit

Measured in mA (letter I), determined by the amount of
electrons that move through a circuit

Impedance : opposition to current flow

Measured in ohms/ (letter R), the measurement of the sum of
all resistance to the flow of current
Electrical Concepts
Ohms Law is a Fundamental Principle of Pacing
Describes the relationship between voltage, current, and resistance

V=IxR
I=V/R
R=V/I
Programming :
Two settings to ensure capture :

Amplitude (V)
The amplitude of the impulse must be large
enough to cause depolarization / to capture the
heart
The amplitude of the impulse must be sufficient
to provide an appropriate pacing safety margin

Pulse width (ms)

The pulse width must be long enough for
depolarization to disperse to the surrounding
tissue
Strength Duration curve

Cardiac Pacemakers Step by Step, 2004

Safety ratio concept for capture
Provide adequate
safety margin

x3
1.5 V

Cardiac Pacemakers Step by Step, 2004

Programming : sensitivity
Factors That Affect Battery Longevity

Lead impedance
Amplitude and pulse width setting
Percentage paced vs. intrinsic events
Rate responsive modes programmed ON
Concepts in pacemaker function
Pacin
goutput of electrical current for depolarizing the cardiac tissue in adjacent of the lead
resulting propagation of a wave of depolarization throughout that chamber

Sensin
gresponse of a pacemaker to intrinsic electrical activity (intrinsic heartbeats)

VVI / 60
 Concepts in pacemaker function
Inhibition of the
output
Pacemaker can inhibit pacing if it senses intrinsic activity pacemaker will not deliver a
stimulus if it senses an intrinsic beat at the proper time

Triggered pacing
Pacemakers deliver a pacing stimulus whenever intrinsic activity is sensed. Most often
used in dual chamber pacemakers

Triggered pacing. (a) and (b) both show atrial sensing, and ventricular pacing, in a tracking mode. The
pacemaker settings are the same in both panels. The difference is that in (b) the intrinsic atrial rate is faster.
 Concepts in pacemaker function
Rate
responsiveness
Pacemakers programmed to vary the pacing rate in response to the patients level of
activity

AV delay
Time interval between an atrial
paced or sensed event, and the
delivery of a ventricular
pacingstimulus analogous to
the intrinsic PR interval

Paced AV delay Sensed AV delay

 NASPE/BPEG Pacemaker Code

A four-letter code is generally used to identify the mode of operation

The Revised NASPE/BPEG Generic Code for Antibradycardia, Adaptive-Rate, and Multisite Pacing, 2002
Common Pacemaker Modes

Response Programmability
Pacing Sensing to Sensing & Rate Response

V O O

- Ventricular pacing
- No sensing
- No response to sensing
Common Pacemaker Modes

Response Programmability
Pacing Sensing to Sensing & Rate Response

V V I

- Ventricular pacing
- Ventricular sensing
- Inhibited when sensing a ventricular event
Common Pacemaker Modes

Response Programmability
Pacing Sensing to Sensing & Rate Response

V V I R

- Ventricular pacing
- Ventricular sensing
- Inhibited when sensing a ventricular event
- Rate response capabilities
Common Pacemaker Modes

Response Programmability
Pacing Sensing to Sensing & Rate Response

D D D

- Dual (Atrial & Ventricular) pacing

- Dual (Atrial & Ventricular) sensing
- Dual (Inhibited & Triggered) response to sensing
 Common Pacemaker Modes

Response Programmability
Pacing Sensing to Sensing & Rate Response

D D D R

- Dual (Atrial & Ventricular) pacing

- Dual (Atrial & Ventricular) sensing
- Dual (Inhibited & Triggered) response to sensing
- Rate Response Capabilities
Indication for pacing : SND
I IIa IIb III
Pacing is indicated when symptoms can clearly
B be attributed to bradycardia

I IIa IIb III Pacing may be indicated when symptoms are

likely to be due to bradycardia, even if the
C
evidence is not conclusive

I IIa IIb III Pacing is not indicated in patients with SB

which is asymptomatic or due to reversible
C causes.
 Indication for pacing : SND
I IIa IIb III Dual-chamber PM with preservation of
vs
VVI A spontaneous AV conduction is indicated for
vs
AAI B reducing the risk of AF and stroke,
avoiding PM syndrome and improving quality
of life

I IIa IIb III Rate response features should be adopted for

patients with chronotropic incompetence,
C
especially if young and physically active
Indication for pacing : Acquired AVB
I IIa IIb III
Pacing is indicated in patients with third- or second-degree
C type 2 AV block irrespective of symptoms

I IIa IIb III Pacing should be considered in patients with second-degree

type 1 AV block which causes symptoms or is found to be
C located at intra- or infra-His levels at EPS

I IIa IIb III Pacing is not indicated in patients with AV block which is
due to reversible causes
C
I IIa IIb III In patients with sinus rhythm, dual-chamber PM should be
preferred to single chamber ventricular pacing for avoiding
A PM syndrome and improving quality of life.
Indication for pacing : Permanent AF and AVB

I IIa IIb III

Ventricular pacing with rate-response function is
C recommended
Indication for pacing : intermittent documented
bradycardia
I IIa IIb III Sinus node disease (including brady-tachy form)
Pacing is indicated in patients affected by sinus node disease who
B have the documentation of symptomatic bradycardia due to sinus
arrest or sinusatrial block

I IIa IIb III Intermittent/paroxysmal AV block (including AF with slow

ventricular conduction)
C Pacing is indicated in patients with intermittent/paroxysmal
intrinsic third- or second degree AV block

Reflex asystolic syncope.

I IIa IIb III
Pacing should be considered in patients 40 years with recurrent,
B unpredictable reflex syncopes and documented symptomatic
pause/s due to sinus arrest or AV block or the combination of the
two
Indication for pacing : intermittent documented
bradycardia
I IIa IIb III Asymptomatic pauses (sinus arrest or AV block).
Pacing should be considered in patients with history of syncope
C and documentation of asymptomatic pauses >6 s due to sinus
arrest, sinus-atrial block or AV block
I IIa IIb III
Pacing is not indicated in reversible causes of bradycardia
C
I IIa IIb III
Intermittent documented bradycardia.
B Preservation of spontaneous AV conduction is recommended

I IIa IIb III Reflex asystolic syncope

Dual-chamber pacing with rate hysteresis is the preferred mode of
C pacing in order to preserve spontaneous sinus rhythm
Indication for pacing : BBB
I IIa IIb III BBB, unexplained syncope and abnormal EPS
Pacing is indicated in patients with syncope, BBB and positive EPS
B defined as HV interval of 70 ms, or second- or third-degree His-
Purkinje block demonstrated during incremental atrial pacing or
with pharmacological challenge

I IIa IIb III

Alternating BBB.
Pacing is indicated in patients with alternating BBB with or
without symptoms

I IIa IIb III

BBB, unexplained syncope non diagnostic investigations.
B Pacing may be considered in selected patients with unexplained
syncope and BBB
I IIa IIb III
Asymptomatic BBB.
B Pacing is not indicated for BBB in asymptomatic patients
Indication for pacing : undocumented reflex
syncope
I IIa IIb III Carotid sinus syncope.
Pacing is indicated in patients with dominant cardioinhibitory
B carotid sinus syndrome and recurrent unpredictable syncope.

I IIa IIb III Tilt-induced cardioinhibitory syncope.

Pacing may be indicated in patients with tilt-induced
B cardioinhibitory response with recurrent frequent unpredictable
syncope and age >40 years after alternative therapy has failed

I IIa IIb III Tilt-induced non-cardioinhibitory syncope.

Cardiac pacing is not indicated in the absence of a documented
B cardioinhibitory reflex
Indication for pacing : unexplained syncope

I IIa IIb III

Unexplained syncope and positive adenosine triphosphate test.
B Pacing may be useful to reduce syncopal recurrences

I IIa IIb III Unexplained syncope.

Pacing is not indicated in patients with unexplained syncope
C without evidence of bradycardia or conduction disturbance.

I IIa IIb III

Unexplained falls.
B Pacing is not indicated in patients with unexplained falls
Optimal pacing mode in sinus node disease and AV block

2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy

Trouble shooting
Undersensing
Oversensing
Lost capture
No output
Pacemaker syndrome
 Undersensing
An intrinsic depolarization that is present, yet not seen or sensed by the
pacemaker

Cause :
Inappropriately programmed sensitivity
Lead dislodgment
Lead failure: Insulation break; conductor fracture
Lead maturation
Change in the native signal
Oversensing
Sensing of an inappropriate signal can be physiologic or nonphysiologic

Cause :
Lead failure
Poor connection at connector block
Exposure to interference
Lost of capture
No evidence of depolarization after pacing artifact

Cause : Less common cause :

Lead dislodgement Twiddlers syndrome
Low output Electrolyte abnormalities e.g., hyperkalemia
Lead maturation Myocardial infarction
Poor connection at connector block Drug therapy
Lead failure Battery depletion
Exit block
No output
Electrical failure cannot reach the heart pacemaker artifacts do not
appear on the ECG; rate is less than the lower rate

Cause :
Poor connection at connector block
Lead failure
Battery depletion
Circuit failure
Pacemaker syndrome
The occurence of overt symptoms due to adverse hemodynamic impact
from the loss of AV synchrony and occurence of ventriculoatrial
conduction or atrial contraction againts closed AV valves in patient
with an implanted pacemaker

Symptoms include:
Dizziness Confussion
Presyncope Malaise
Chest tightness Fatigue
Shortness of breath

Cause :
Loss of capture Single chamber system
A-V intervals of long duration Absence of rate increase with exercise
Onset of 2:1 block
Thank you...