This document provides an overview of pacemakers and implantable cardioverter defibrillators (ICDs). It discusses the different types of pacemakers including single-chamber pacemakers (VVI), dual-chamber pacemakers (DDD), and biventricular pacemakers (CRT). It outlines the indications for pacemaker and ICD implantation and reviews potential complications of the procedures such as infection, lead issues, and pacemaker syndrome. Guidelines for device implantation and management are summarized including recommendations on timing after heart events, upgrades, and device selection. Risks associated with dual chamber devices are also mentioned.

1. Pacemakers and ICDs
An Overview
Samir Morcos Rafla, FACC, FESC, FHRS
Emeritus professor of cardiology
Alexandria University
smrafla@yahoo.com
0201001495577
Dr. Samir Rafla Lectures

2. 2018 ACC/AHA/HRS Guideline on the
Evaluation and Management of
Patients With Bradycardia and
Cardiac Conduction Delay
Developed in Collaboration With and Endorsed by the American
Association for Thoracic Surgery, the Pediatric & Congenital
Electrophysiology Society, and the Society of Thoracic Surgeons
© American College of Cardiology Foundation and American Heart Association

3. 3
Nomenclature for pacemakers
Letter 1 Letter 2 Letter 3 Letter 4 Letter 5
Chamber
Paced
Chamber
Sensed
Sensing
Response
Programmabilit
y
Antitachycar
dia
Functions
A = atrium A = atrium T=triggered P = simple P = pacing
V=ventricle V=ventricle I = inhibited M=multiprogra
mmable
S = shock
D = dual D = dual D = dual (A
and V
inhibited)
R=rate adaptive D = dual
(shock +
pace)
O = none O = none O = none C=communicati
ng O = none

4. Code Indication Advantages Disadvantages
VVI Intermittent backup
pacing; inactive patient
Simplicity; low cost
Fixed rate;
risk of pacemaker
syndrome
VVIR Atrial fibrillation Rate responsive Requires
advanced
programming
DDD Complete heart block Atrial tracking
restores normal
physiology
No rate
responsiveness;
requires two leads
and advanced
programming
DDDR Sinus node dysfunction;
atrioventricular block and
need for rate
responsiveness
Universal pacer; all
options available by
programming
Complexity, cost,
programming, and
follow-up
evaluation
Common Permanent Pacemakers

5. 526-Nov-20

6. Pacemaker leads
tips showing
fixation by screws
and hooks

7. 7

8. Pacemaker Configurations
VOO
Indications
Temporary mode some-times used during surgery to
prevent interference from electrocautery

9. Pacemaker Configurations
VVI
Indications
The combination of AV block and chronic atrial arrhythmias
(particularly atrial fibrillation).

10. Pacemaker Configurations
VDD
Indications
AV block with intact sinus node function (particularly
useful in congenital AV block).

11. Pacemaker Configurations
DDD
Indications
1. The combination of AV block and SSS.
2. Patients with LV dysfunction and LV hypertrophy who need
coordination of atrial and ventricular contractions to maintain
adequate CO.

12. 12

13. Normal VVI pacemaker (rhythm strip).
a patient with a VVI pacemaker implanted for the treatment of
symptomatic complete heart block.
The pacing rate is approximately 75 beats/min (determined by
measuring the time between consecutive pacemaker spikes).
Each pacemaker spike is followed by a paced QRS complex.

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17. Permanent Pacing for Atrioventricular Block
(continued)
Recommendations for Permanent Pacing for Chronic
Therapy/Management of Bradycardia Attributable to Atrioventricular
Block
COR LOE Recommendation
I C-LD
In patients with permanent AF and symptomatic
bradycardia, permanent pacing is recommended.
I C-LD
In patients who develop symptomatic atrioventricular
block as a consequence of guideline-directed
management and therapy for which there is no
alternative treatment and continued treatment is
clinically necessary, permanent pacing is
recommended to increase heart rate and improve
symptoms.

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GUIDELINES OF CRT Indications
Class I
CRT is indicated for patients who have
LVEF <35%, sinus rhythm, left bundle
branch block (LBBB) with a QRS duration >
150 ms, and NYHA Fc II, III, or ambulatory
Fc IV symptoms on guideline-directed
medical therapy (GDMT). (Level of
Evidence: A for NYHA Fc III-IV; Level of
Evidence: B for NYHA Fc II)

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Class IIa
1. CRT can be useful for patients who have LVEF <
35%, sinus rhythm, LBBB with a QRS duration 130
to 149 ms, and NYHA Fc II, III, or ambulatory Fc IV
symptoms on GDMT. (Level of Evidence: B)
2. CRT can be useful for patients who have LVEF <
35%, sinus rhythm, a non-LBBB pattern with a QRS
duration > 150 ms, and NYHA Fc III/ambulatory Fc IV
symptoms on GDMT. (Level of Evidence: A)
3. CRT can be useful in patients with atrial
fibrillation and LVEF < 35% on GDMT if: (a) The
patient requires ventricular pacing or otherwise
meets CRT criteria and (b) AV nodal ablation or
pharmacologic rate control will allow near 100%
ventricular pacing with CRT. (Level of Evidence: B)

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CRT- Isolated loss of LV pacing

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36. 36

37. Table- Indications for lead extraction.
Class I (conditions for which there is general
agreement that leads should be removed). When a
lead or lead fragment causes:
Sepsis (including endocarditis).
Life-threatening arrhythmias.
An immediate or imminent physical threat to the
patient (including retained extraction hardware).
Clinically significant thromboembolic events.
Obliteration or occlusion of all useable veins, with
the need to implant a new transvenous pacing
system.
Interference with the operation of another implanted
device. 37

38. Major complications of lead extraction
Death
Cardiac avulsion or tear requiring intervention
Vascular avulsion or tear requiring intervention
Hemothorax or severe bleeding from any source
requiring transfusion
Pneumothorax requiring chest tube drainage
Pulmonary embolism requiring surgical
intervention
Respiratory arrest
Septic shock
Stroke
38

39. Perioperative management with use of electrocautery in patients who
have implanted cardiac devices.
Preoperatively
Identify pacemaker and determine 'reset' mode
Check pacemaker program, telemetry, thresholds, battery status
Deactivate rate response and, if applicable, Vario function
Record pacemaker information
Intraoperatively
Position the indifferent plate for electrocautery away from pacemaker so that
pacemaker is not between electrocautery electrodes
Monitor pulse or oximeter (electrocardiogram is obscured by artifacts)
Have programmer readily available
Use bipolar cautery when possible
Do not use cautery near pacemaker
Use cautery in short bursts
Reprogram, if necessary, if reset mode is hemodynamically unstable
Postopemtively
Check pacemaker program, telemetry, thresholds. Reprogram if necessary39

40. Complications of
Implantation
Infection.
Thrombophlebitis .
The “Pacemaker Syndrome” .
Pacemaker Malfunction.

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43. Complications of pacing and CRT
implantation
- Lead complications are the main reason for re-
operation after implantation of PM or CRT devices; lead
complications occurred in 3.6% of patients.
- Complication rates were reported in 15.6, 18.3 and
19.7% of the patients at 1, 3 and 5 years,
respectively.
- Major complications were higher with CRT-D,
compared with PM replacements.
- Infection is one of the most worrying post-operative
complications; the incidence was 4.8 per 1000 PM-
years during the first year.
43

44. Complications of Implantation
The “Pacemaker Syndrome”:
* After implantation, in 20%.
* A pt. may present with new complaints or a worsening of the
symptoms that prompted evaluation & eventual pacemaker
therapy.
* These include syncope or near-syncope, orthostatic dizziness,
fatigue, exercise intolerance, weakness, lethargy, chest fullness
or pain, cough, uncomfortable pulsations in the neck or
abdomen, right upper quadrant pain, and other nonspecific
symptoms.

45. Complications of Implantation
The “Pacemaker Syndrome”:
* The aetiology :is the loss of AV synchrony &
* Is most common with VVI pacing
* Elevated (BNP) & diuresis .
* DDI pacing in a pt. with AV block may result in this syndrome
if the sinus node discharge rate exceeds the programmed rate
of the pacemaker.
* Rx: replacing a VVI pacemaker with a dual-chamber
pacemaker or lowering the pacing rate of the VVI unit.
* Consultation with a cardiologist is recommended .

46. Complications of Implantation
Pacemaker Malfunction :
Failure to capture
* Lead disconnection, break, or displacement
* Exit block
* Battery depletion
Undersensing
* Lead displacement
* Inadequate endocardial lead contact
* Low-voltage intracardiac p waves and QRS complexes
* Lead fracture
Oversensing
* Sensing extracardiac signals: myopotentials
* T wave sensing
Inappropriate rate
* Battery depletion
* Ventriculoatrial conduction with pacemaker-mediated
tachycardia
* 1:1 response to atrial dysrhythmias

47. Pacemaker Malfunction.
Failure to Capture:
* Electrical stimuli delivered by the pacemaker
does not initiate depolarization of the atria or
ventricle

48. Failure to Capture
Possible Causes Corrective Measures
•Threshold rise • Increase output (mA)/check thresholds
•Fractured/dislodged lead • Replace/reposition lead
•Battery depletion • Replace battery
•QRS not visible • Adjust ECG
•Tissue is refractory • Assess mode selection
•Faulty cable connections • Check connections
• Switch polarity (epicardial system

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CRT trials showed that the implantation success
rate was 94.4%; peri-implantation deaths
occurred in 0.3% of trial participants, mechanical
complications (including coronary sinus
dissection or perforation, pericardial effusion or
tamponade, pneumothorax and haemothorax) in
3.2%, lead problems in 6.2% and infections in
1.4%.
Haematomas are very frequent (2.9–9.5% of the
cases). Aspirin carries a two-fold risk of bleeding
and dual antiplatelet therapy carries a four-fold
risk of bleeding during the peri-operative period.

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Indication for cardiac pacing in patients with
hypertrophic cardiomyopathy
ClassRecommendations
IIb1) Left ventricular outflow tract obstruction.
Sequential AV pacing with short AV interval
may be considered in selected patients with
resting or provocable LV outflow tract
obstruction and drug-refractory symptoms
who:
a) have contraindications for septal alcohol
ablation or septal myectomy;
b) or are at high risk of developing heart
block following septal alcohol ablation
or septal myectomy.

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Pacing after cardiac surgery, transcatheter aortic
valve implantation and heart transplantation
ClassRecommendations
I1) High degree or complete AV block
after cardiac surgery and TAVI. A period
of clinical observation up to 7 days is
indicated in order to assess whether the
rhythm disturbance is transient and
resolves.

52. 52
Pacing in acute myocardial infarction
Indications for permanent pacing
ClassRecommendations
I1) In the rare cases in which AV block
becomes permanent (after 14 days of
temporary pacing), permanent cardiac
pacing is indicated.

53. IMPLANTABLE CARDIOVERTER-
DEFIBRILLATORS ICD
Class I Indications:
1. Cardiac arrest resulting from VF or VT not caused by
a transient or reversible event.
2. Spontaneous sustained VT.
3. Syncope of undetermined origin with clinically
relevant, hemodynamically significant sustained VT or VF
induced at electrophysiologic study when drug therapy is
ineffective, not tolerated, or not preferred.
4. Nonsustained VT with coronary artery disease, prior
myocardial infarction, left ventricular dysfunction, and
inducible VF or sustained VT at electrophysiologic study
that is not suppressible by a class I antiarrhythmic drug.

54. Recommendations on Implantation of ICDs without
Cardiac Resynchronization Capabilities
Primary Prevention
ICD therapy is recommended for primary
prevention to reduce total mortality by a
reduction in SCD in patients with LV dysfunction
due to prior MI who are at least 40 days post-MI,
have an LVEF ≤30%–40%, are NYHA Class II
or III receiving chronic optimal medical therapy,
and have a reasonable expectation of survival
with a good functional status for more than 1
year. 54

55. Secondary Prevention
- ICD therapy is recommended for secondary
prevention of SCD in patients who survived VF or
hemodynamically unstable VT, or VT with syncope and
who have an LVEF ≤40%, who are receiving chronic
optimal medical therapy, and who have a reasonable
expectation of survival with good functional status for
more than 1 year.
- An ICD should be implanted in patients with
nonischemic DCM and significant LV dysfunction who
have sustained VT or VF, are receiving chronic optimal
medical therapy, and who have reasonable expectation
of survival with good functional status for more than 1
year.
55

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Potential Risks of Dual-Chamber Device Selection
The addition of an atrial lead to an ICD system also
poses several potential risks. Additional leads are
associated with increased risk of dislodgement and
other complications, including an increased risk of
periprocedural mortality in dual-chamber ICD recipients
compared with those who receive single-chamber
devices.
Battery life tends to be somewhat shorter in dual-
chamber devices, which might lead to a greater need
for generator replacement over patients’ lifetimes.
Additional leads can also present a risk of lead failure
and/or recall, and in the event of infection or other
factors that require lead extraction, additional leads
present an incremental risk of vascular complications.

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ICD Implantation Within 40 Days of a
Myocardial Infarction
In the great majority of situations, ICD
implantation should be performed at least 40
days after an MI. During the acute phase
of MI, it is often unclear how much recovery of
cardiac function will occur following hospital
discharge, and in some cases, the clinical
condition is so severe that ICD implantation
would be of little value.

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Leadless Pacemaker

59. LifeVest and –
Wearable
automatic external
defibrillator (AED)