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Pacemaker Basics

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  1. 1. Conduction System of Heart
  2. 2. PacemakersDevices that deliver localised electricalstimulation to cardiac tissueTypes– Temporary / Permanent– Epicardial / Endocardial– Transvenous / Epicardial /Transcutaneous/ Esophageal– Single chamber / Dual chamber
  3. 3. IndicationsSymptomatic Sinus node dysfunctionAtrioventricular Block – second- or third-degreeBifascicular and Trifascicular BlockNeurocardiogenic SyncopeHypersensitive Carotid Sinus SyndromeHypertrophic CardiomyopathyLeft Ventricular Systolic Dysfunction – Cardiac Resynchronization Therapy (CRT)Hypertrophic CardiomyopathyLong QT SyndromePrevention and Termination of Tachyarrhythmias – Anti Tachycardia Pacing (ATP)
  4. 4. The Four Parts of the Pacing SystemThe Pulse GeneratorThe lead(s)The patient care system (“programmer” )And the patient!
  5. 5. Pulse generatorCasing ( “can”)– TitaniumConnectorComponents– Diodes, resistors, oscillator, microchipsBattery– Lithium iodide
  6. 6. Lead system Screw-in
  7. 7. Epicardial LeadFastened (sutured) to outside of heartRequires open-chest procedureHas corkscrew mechanism
  8. 8. The NBG CodePosition I II III IV VCategory Chamber(s) Chamber(s) Response to Rate Multisite paced sensed sensing Modulation PacingLetters O= None O= None O=None O=None O=None A=Atrium A=Atrium T=Triggered R=Rate A=Atrium V=Ventricle V=Ventricle I=Inhibited Modulation V=Ventricle D=Dual D=Dual D=Dual D=Dual S=Single* S=Single*
  9. 9. Implantation LabHigh quality fluoroscopyMonitoring– 12 channel ECG– BP (invasive/non-invasive)– SpO2– Defibrillator– Programmer– Oxygen– Suction– Intubation– Crash cart
  10. 10. Lab personnel2 Cardiologists– First operator (should have performed 70 implants)– Assistant2 Nurses– Scrub nurse– Monotoring nurseCathlab technologistAnesthetist on- call
  11. 11. Pre-implant protocolThorough evaluation of the patient – medical records esp. anticoagulants, antiplatelets – previous reactions to drugs and contrast – basic laboratory tests (coag.parameters, Xray,Echo)Indication for pacing should be clearType of pacing system – single / dualInformed consentFood is withheld for 6 to 8 hoursIntravenous line – HydrationHeparin stopped 6 hrsAntiplatelets stopped 5 daysInternational Normalized Ratio (INR)<1.2Antibiotic prophylaxis is controversialMild pre-procedural sedationPrepare nipple line to the angle of the jaw bilaterally
  12. 12. ApproachesThe Subclavian Method – Seldinger approach to the subclavian vein – Most popular method – Subclavian “stick” using an 18-G needle – 2 separate subclavian punctures when placing a dual chamber pacingAxillary Vein ApproachCephalic Vein Approach – almost no risk of pneumothorax or hemothorax
  13. 13. Parameters
  14. 14. Post-procedure managementElectrocardiogramAnalgesicsAntibioticsLimit motion of the ipsilateral upper extremityfor 1 weekBefore discharge, the device is programmed
  15. 15. Complications
  16. 16. Complications
  17. 17. Advice on dischargeCarry ID card showing “PPI implant”Avoid EMI – Arc-welding machines, digital cell phones, – Anti-theft alarms, metal detectorsMRI contraindicatedECSWLRadiationDC cardioversionRF ablationElectro-cautery
  18. 18. Thank You