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Temporary and Permanent Cardiac Pacing

Temporary and Permanent Cardiac Pacing. IntroductionTemporary pacing : Indications, TechniquePermananent Pacing : Pacemaker Nomenclature Indications Selection of Pacing Mode Pacing for Hemodynamic Improvement Pacemaker Implantation, Complications Pacemaker Troubleshooting .

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Temporary and Permanent Cardiac Pacing

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    1. Temporary and Permanent Cardiac Pacing

    3. Temporary Cardiac Pacing Transvenous Transcutaneous Epicardial Transesophageal

    4. Indications for Temporary Pacing Acute myocardial infarction with: CHB, Mobitz type 2 AV block, medically refractory symptomatic bradycardia, alternating BBB, new bifascicular block, new BBB with anterior MI In absence of acute MI : SSS, CHB, Mobitz type 2 AV block Treatment of tachyarrhythmias : VT

    5. Temporary Transvenous Pacing Unipolar Electrograms

    6. Paced QRS Morphology

    7. Permanent Pacing

    8. The Pacemaker System Patient

    9. Pacemaker Implantation Epicardial 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

    10. Codes Describing Pacemaker Modes

    11. DDD

    12. Indications for Pacing for AV Block

    13. Indications for Pacing for Sinus Node Dysfunction

    14. Pacing for Hemodynamic Improvement Hypertrophic Obstructive Cardiomyopathy Cardiac Resynchronization Therapy Pacing to Prevent AF Pacing in Long QT Syndrome Neurocardiogenic Syncope

    15. 15 Mode Selection Considerations Status of Atrial Rhythm - Intrinsic vs. Paced - Presence of Atrial Tachyarrhythmias: Acute/Chronic Status of AV Conduction Normal -Slowed-Blocked Presence of Chronotropic Incompetence

    16. Choice of Pacing Mode

    17. Rate Responsive Pacing Goal: To provide an increased heart rate for the chronotropic incompetent patient The Pacemaker: Allows programming of a minimum rate and a maximum rate Is allowed to pace (in response to sensor input) at any rate in-between this min and max rate

    18. Today’s Sensors Vibration non-physiologic Acceleration non-physiologic Minute Ventilation physiologic Temperature physiologic

    19. Pacemaker Implantation

    21. Sensing

    22. 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

    23. Dual Chamber Pacemaker

    24. Pacemaker – Magnet Application

    25. Pacemaker – Mode Switch ( 1 of 3 )

    26. Mode Switching in a Dual Chamber Pacemaker ( 2 of 3 )

    27. Mode Switching in a Dual Chamber Pacemaker ( 3 of 3 )

    28. Acute Complications of Pacemaker Implantation Venous access 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

    29. Delayed Complications of Pacemaker Therapy 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

    30. Pacemaker Troubleshooting Failure to capture – high threshold,lead dislodgement, conductor coil fracture Failure to pace ( failure to output ) – oversensing, circuit interruption, battery depletion Failure to sense – undersensing, oversensing

    31. Intermittent Loss of Ventricular Capture

    32. Myopotential Sensing

    34. “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

    35. Sources of Electromagnetic Interference Medical MRI Lithotripsy Electrocautery/cryosurgery External defibrillators Therapeutic radiation Nonmedical Arc welding equipment Automobile engines Radar Transmitters

    36. Expanded Indications for Pacing Cardiac resynchronization therapy Hypertrophic cardiomyopathy Neurocardiogenic syncope Long QT syndrome Prevention of atrial fibrillation

    37. Normal Conduction Is Important 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

    38. Heart Failure Delayed Ventricular Activation

    39. Heart Failure Bifocal Ventricular Pacing

    40. Bi-Ventricular Pacing

    43. Baseline ECG

    44. Bi-V Pace

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