Temporary Pacing

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Temporary Pacing

  1. 1. Temporary Pacing William H. Sauer, MD
  2. 2. Road Map <ul><li>Indications </li></ul><ul><li>Methods for Placement </li></ul><ul><li>Basic Programming </li></ul>
  3. 3. Road Map <ul><li>Indications </li></ul><ul><li>Methods for Placement </li></ul><ul><li>Basic Programming </li></ul>
  4. 4. Indications <ul><li>Bradycardia in the Setting of MI </li></ul><ul><li>Bradycardia not related to MI </li></ul><ul><li>Prevention of VT/VF </li></ul><ul><li>Prophylaxis </li></ul>
  5. 5. Slow Heart Rates peri MI <ul><li>Mobitz II after an anterior MI </li></ul><ul><li>New fascicular block and long PR </li></ul><ul><li>Alternating Bundle Branch Block </li></ul><ul><li>Medically Refractory Sinus Node Dysfunction </li></ul><ul><li>Third Degree AV block </li></ul>
  6. 6. Bradycardia not related to MI <ul><li>Medically Refractory Symptomatic Bradycardia </li></ul><ul><li>Third degree AV block with wide QRS escape </li></ul>
  7. 7. Prevention of VT/VF <ul><li>TdP relies on bradycardia dependence (long-short sequence) </li></ul><ul><li>Long QT3 – bradycardia dependent </li></ul><ul><li>MMVT requiring frequent ATP </li></ul>
  8. 8. Prophylactic Implant <ul><li>Patients with LBBB requiring Swan-Ganz catheter placement </li></ul><ul><li>Cardioversion in the setting of SSS </li></ul><ul><li>New BBB in the setting of acute endocarditis </li></ul><ul><li>Peri-operatively </li></ul>
  9. 9. Road Map <ul><li>Indications </li></ul><ul><li>Methods for Placement </li></ul><ul><li>Basic Programming </li></ul>
  10. 10. Types of Temporary Pacers <ul><li>Transcutaneous </li></ul><ul><li>Transesophogeal </li></ul><ul><li>Epicardial </li></ul><ul><li>Transvenous </li></ul>
  11. 11. Types of Temporary Pacers <ul><li>Transcutaneous </li></ul><ul><li>Transesophogeal </li></ul><ul><li>Epicardial </li></ul><ul><li>Transvenous </li></ul>
  12. 12. Equipment <ul><li>7F introducer and prep kit </li></ul><ul><li>Mobile C-Arm Fluoroscopy </li></ul><ul><li>Pacing Lead </li></ul><ul><li>External Pacemaker </li></ul><ul><li>Suture and Tegaderm </li></ul>
  13. 13. Access <ul><li>Leave the subclavian vein alone – an EP will need this space to implant the permanent pacer or ICD </li></ul><ul><li>Right IJ is easiest access to the right ventricle </li></ul><ul><li>Femoral Vein is next easiest to move a non-deflectable catheter to the RV </li></ul><ul><li>Left IJ is last resort </li></ul>
  14. 14. The pacing lead <ul><li>The lead is a spear that will pierce the heart – be gentle </li></ul><ul><li>Balloon-tipped catheters are preferable </li></ul><ul><li>The pacing port on the SGC is lethal </li></ul><ul><li>Leave a little bit of slack – but do not make the lead buckle in the heart </li></ul>
  15. 15. Road Map <ul><li>Indications </li></ul><ul><li>Methods for Placement </li></ul><ul><li>Basic Programming </li></ul>
  16. 16. 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
  17. 17. Single Chamber Timing Terminology <ul><li>Lower rate </li></ul><ul><li>Refractory period </li></ul><ul><li>Blanking period </li></ul><ul><li>Upper rate </li></ul>
  18. 18. Lower Rate Interval <ul><li>Defines the lowest rate the pacemaker will pace </li></ul>Lower Rate Interval VVI / 60 VP VP
  19. 19. Refractory Period <ul><li>Interval initiated by a paced or sensed event </li></ul><ul><li>Designed to prevent inhibition by cardiac or non-cardiac events </li></ul>Lower Rate Interval VVI / 60 VP VP Refractory Period
  20. 20. Blanking Period <ul><li>The first portion of the refractory period </li></ul><ul><li>Pacemaker is “blind” to any activity </li></ul><ul><li>Designed to prevent oversensing pacing stimulus </li></ul>Lower Rate Interval VVI / 60 Blanking Period Refractory Period VP VP
  21. 21. VOO Mode <ul><li>Asynchronous pacing delivers output regardless of intrinsic activity </li></ul>Lower Rate Interval VOO / 60 Blanking Period VP VP
  22. 22. <ul><li>Atrial Pace, Ventricular Pace (AP/VP) </li></ul>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
  23. 23. <ul><li>Atrial Pace, Ventricular Sense (AP/VS) </li></ul>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
  24. 24. <ul><li>Atrial Sense, Ventricular Pace (AS/ VP) </li></ul>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
  25. 25. <ul><li>Atrial Sense, Ventricular Sense (AS/VS) </li></ul>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
  26. 26. Dual Chamber Timing Parameters <ul><li>Lower rate </li></ul><ul><li>AV and VA intervals </li></ul><ul><li>Upper rate intervals </li></ul><ul><li>Refractory periods </li></ul><ul><li>Blanking periods </li></ul>
  27. 27. Lower Rate <ul><li>The lowest rate the pacemaker will pace the atrium in the absence of intrinsic atrial events </li></ul>Lower Rate Interval AP VP AP VP DDD 60 / 120
  28. 28. AV Intervals <ul><li>Initiated by a paced or non-refractory sensed atrial event </li></ul><ul><ul><li>Separately programmable AV intervals – SAV /PAV </li></ul></ul>Lower Rate Interval DDD 60 / 120 AP VP AS VP PAV SAV 200 ms 170 ms
  29. 29. AV Intervals <ul><li>Initiated by a paced or non-refractory sensed atrial event </li></ul><ul><ul><li>Separately programmable AV intervals – SAV /PAV </li></ul></ul>Lower Rate Interval DDD 60 / 120 AP VP AS VP PAV SAV 200 ms 170 ms
  30. 30. Atrial Escape Interval (V-A Interval) Lower rate interval – AV interval V-A interval
  31. 31. <ul><li>The interval initiated by a paced or sensed ventricular event to the next atrial event </li></ul>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
  32. 32. Refractory Periods <ul><li>VRP and PVARP are initiated by sensed or paced ventricular events </li></ul><ul><ul><li>The VRP is intended to prevent self-inhibition such as sensing of T-waves </li></ul></ul><ul><ul><li>The PVARP is intended primarily to prevent sensing of retrograde P waves </li></ul></ul>Post Ventricular Atrial Refractory Period (PVARP) AP VP Ventricular Refractory Period (VRP) A-V Interval (Atrial Refractory)
  33. 33. Blanking Periods <ul><li>First portion of the refractory period-sensing is disabled </li></ul>AP VP AP Post Ventricular Atrial Blanking (PVAB) Post Atrial Ventricular Blanking Ventricular Blanking (Nonprogrammable) Atrial Blanking (Nonprogrammable)
  34. 34. Upper Rate Behaviors – Wenckebach and 2:1 Block Lower rate Atrial rate Ventricular rate Upper rate Atrial tracking
  35. 35. Total Atrial Refractory Period (TARP) <ul><li>Sum of the AV Interval and PVARP </li></ul>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
  36. 36. Wenckebach Operation <ul><li>Prolongs the SAV until upper rate limit expires </li></ul><ul><ul><li>Produces gradual change in tracking rate ratio </li></ul></ul>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
  37. 37. Wenckebach Operation DDD / 60 / 120 / 310
  38. 38. <ul><li>Every other P wave falls into refractory and does not restart the timing interval </li></ul>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
  39. 39. 2:1 Block DDD / 60 / 120 / 310
  40. 40. Cases
  41. 41. Syncope - Indication for Temporary Pacer?
  42. 42. Asymptomatic - Indication for Temporary Pacer?
  43. 43. Asymptomatic - Indication for Temporary Pacer?
  44. 44. Asymptomatic when lying down
  45. 45. Is This Normal Device Operation?
  46. 46. Is This Normal Device Operation? What Feature Might You Want to Have Programmed On?
  47. 47. Is This Normal Device Operation?
  48. 48. Is This Normal Device Operation?

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