• Share
  • Email
  • Embed
  • Like
  • Save
  • Private Content
Temporary Pacing
 

Temporary Pacing

on

  • 4,961 views

 

Statistics

Views

Total Views
4,961
Views on SlideShare
4,617
Embed Views
344

Actions

Likes
1
Downloads
132
Comments
0

3 Embeds 344

http://www.cardiologylinks.org 296
http://cardiologylinks.webs.com 47
http://translate.googleusercontent.com 1

Accessibility

Categories

Upload Details

Uploaded via as Microsoft PowerPoint

Usage Rights

© All Rights Reserved

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Processing…
Post Comment
Edit your comment

    Temporary Pacing Temporary Pacing Presentation Transcript

    • Temporary Pacing William H. Sauer, MD
    • Road Map
      • Indications
      • Methods for Placement
      • Basic Programming
    • Road Map
      • Indications
      • Methods for Placement
      • Basic Programming
    • Indications
      • Bradycardia in the Setting of MI
      • Bradycardia not related to MI
      • Prevention of VT/VF
      • Prophylaxis
    • Slow Heart Rates peri MI
      • Mobitz II after an anterior MI
      • New fascicular block and long PR
      • Alternating Bundle Branch Block
      • Medically Refractory Sinus Node Dysfunction
      • Third Degree AV block
    • Bradycardia not related to MI
      • Medically Refractory Symptomatic Bradycardia
      • Third degree AV block with wide QRS escape
    • Prevention of VT/VF
      • TdP relies on bradycardia dependence (long-short sequence)
      • Long QT3 – bradycardia dependent
      • MMVT requiring frequent ATP
    • Prophylactic Implant
      • Patients with LBBB requiring Swan-Ganz catheter placement
      • Cardioversion in the setting of SSS
      • New BBB in the setting of acute endocarditis
      • Peri-operatively
    • Road Map
      • Indications
      • Methods for Placement
      • Basic Programming
    • Types of Temporary Pacers
      • Transcutaneous
      • Transesophogeal
      • Epicardial
      • Transvenous
    • Types of Temporary Pacers
      • Transcutaneous
      • Transesophogeal
      • Epicardial
      • Transvenous
    • Equipment
      • 7F introducer and prep kit
      • Mobile C-Arm Fluoroscopy
      • Pacing Lead
      • External Pacemaker
      • Suture and Tegaderm
    • Access
      • Leave the subclavian vein alone – an EP will need this space to implant the permanent pacer or ICD
      • Right IJ is easiest access to the right ventricle
      • Femoral Vein is next easiest to move a non-deflectable catheter to the RV
      • Left IJ is last resort
    • The pacing lead
      • The lead is a spear that will pierce the heart – be gentle
      • Balloon-tipped catheters are preferable
      • The pacing port on the SGC is lethal
      • Leave a little bit of slack – but do not make the lead buckle in the heart
    • Road Map
      • Indications
      • Methods for Placement
      • Basic Programming
    • NBG Code Review I Chamber Paced II Chamber Sensed III Response to Sensing IV Programmable Functions/Rate Modulation V Antitachy Function(s) V: Ventricle V: Ventricle T: Triggered P: Simple programmable P: Pace A: Atrium A: Atrium I: Inhibited M: Multi- programmable S: Shock D: Dual (A+V) D: Dual (A+V) D: Dual (T+I) C: Communicating D: Dual (P+S) O: None O: None O: None R: Rate modulating O: None S: Single (A or V) S: Single (A or V) O: None
    • Single Chamber Timing Terminology
      • Lower rate
      • Refractory period
      • Blanking period
      • Upper rate
    • Lower Rate Interval
      • Defines the lowest rate the pacemaker will pace
      Lower Rate Interval VVI / 60 VP VP
    • Refractory Period
      • Interval initiated by a paced or sensed event
      • Designed to prevent inhibition by cardiac or non-cardiac events
      Lower Rate Interval VVI / 60 VP VP Refractory Period
    • Blanking Period
      • The first portion of the refractory period
      • Pacemaker is “blind” to any activity
      • Designed to prevent oversensing pacing stimulus
      Lower Rate Interval VVI / 60 Blanking Period Refractory Period VP VP
    • VOO Mode
      • Asynchronous pacing delivers output regardless of intrinsic activity
      Lower Rate Interval VOO / 60 Blanking Period VP VP
      • Atrial Pace, Ventricular Pace (AP/VP)
      Four “Faces” of Dual Chamber Pacing Rate = 60 bpm / 1000 ms A-A = 1000 ms V-A AV V-A AV AP VP AP VP
      • Atrial Pace, Ventricular Sense (AP/VS)
      Four “Faces” of Dual Chamber Pacing Rate = 60 ppm / 1000 ms A-A = 1000 ms AP VS AP VS V-A AV V-A AV
      • Atrial Sense, Ventricular Pace (AS/ VP)
      Four “Faces” of Dual Chamber Pacing AS VP AS VP Rate (sinus driven) = 70 bpm / 857 ms A-A = 857 ms V-A AV AV V-A
      • Atrial Sense, Ventricular Sense (AS/VS)
      Four “Faces” of Dual Chamber Pacing Rate (sinus driven) = 70 bpm / 857 ms Spontaneous conduction at 150 ms A-A = 857 ms AS VS AS VS V-A AV AV V-A
    • Dual Chamber Timing Parameters
      • Lower rate
      • AV and VA intervals
      • Upper rate intervals
      • Refractory periods
      • Blanking periods
    • Lower Rate
      • The lowest rate the pacemaker will pace the atrium in the absence of intrinsic atrial events
      Lower Rate Interval AP VP AP VP DDD 60 / 120
    • AV Intervals
      • Initiated by a paced or non-refractory sensed atrial event
        • Separately programmable AV intervals – SAV /PAV
      Lower Rate Interval DDD 60 / 120 AP VP AS VP PAV SAV 200 ms 170 ms
    • AV Intervals
      • Initiated by a paced or non-refractory sensed atrial event
        • Separately programmable AV intervals – SAV /PAV
      Lower Rate Interval DDD 60 / 120 AP VP AS VP PAV SAV 200 ms 170 ms
    • Atrial Escape Interval (V-A Interval) Lower rate interval – AV interval V-A interval
      • The interval initiated by a paced or sensed ventricular event to the next atrial event
      Lower Rate Interval AV Interval VA Interval Atrial Escape Interval (V-A Interval) DDD 60 / 120 PAV 200 ms; V-A 800 ms 200 ms 800 ms AP VP AP VP
    • Refractory Periods
      • VRP and PVARP are initiated by sensed or paced ventricular events
        • The VRP is intended to prevent self-inhibition such as sensing of T-waves
        • The PVARP is intended primarily to prevent sensing of retrograde P waves
      Post Ventricular Atrial Refractory Period (PVARP) AP VP Ventricular Refractory Period (VRP) A-V Interval (Atrial Refractory)
    • Blanking Periods
      • First portion of the refractory period-sensing is disabled
      AP VP AP Post Ventricular Atrial Blanking (PVAB) Post Atrial Ventricular Blanking Ventricular Blanking (Nonprogrammable) Atrial Blanking (Nonprogrammable)
    • Upper Rate Behaviors – Wenckebach and 2:1 Block Lower rate Atrial rate Ventricular rate Upper rate Atrial tracking
    • Total Atrial Refractory Period (TARP)
      • Sum of the AV Interval and PVARP
      PVARP Upper Tracking Rate Lower Rate Interval { P Waves Blocked AS AS VP VP SAV = 200 ms PVARP = 300 ms Thus TARP = 500 ms (120 ppm) DDD LR = 60 ppm (1000 ms) UTR = 100 bpm (600 ms) Sinus rate = 66 bpm (900 ms) SAV TARP PVARP SAV
    • Wenckebach Operation
      • Prolongs the SAV until upper rate limit expires
        • Produces gradual change in tracking rate ratio
      PVARP Upper Tracking Rate Lower Rate Interval { AS AS AR AP VP VP VP TARP SAV PAV PVARP SAV PVARP P Wave Blocked (unsensed or unused) DDD Sinus rate = 109 bpm (550 ms) LR = 60 bpm (1000 ms) UTR = 100 ppm (600 ms) SAV = 200 ms PAV = 230 ms PVARP = 300 ms TARP TARP
    • Wenckebach Operation DDD / 60 / 120 / 310
      • Every other P wave falls into refractory and does not restart the timing interval
      2:1 Block Upper Tracking Limit Lower Rate Interval { { P Wave Blocked Sinus rate = 150 bpm (450 ms) PVARP = 300 ms SAV = 200 ms Tracked rate = 66 bpm (900 ms) AV PVARP AV PVARP TARP TARP AS AS VP VP AR AR
    • 2:1 Block DDD / 60 / 120 / 310
    • Cases
    • Syncope - Indication for Temporary Pacer?
    • Asymptomatic - Indication for Temporary Pacer?
    • Asymptomatic - Indication for Temporary Pacer?
    • Asymptomatic when lying down
    • Is This Normal Device Operation?
    • Is This Normal Device Operation? What Feature Might You Want to Have Programmed On?
    • Is This Normal Device Operation?
    • Is This Normal Device Operation?
    •