A pacemaker is a medical device that uses electrical pulses to regulate an abnormal heart rhythm. The first pacemaker was implanted in 1958. Modern pacemakers are battery-powered and implanted surgically. They have leads placed in the heart to sense the heart's rhythm and deliver electrical pulses when needed. Pacemakers are programmed to pace one or both chambers of the heart and can inhibit or trigger pacing. Common indications include sinus node dysfunction and heart block. Pacemaker implantation involves accessing a vein, placing leads in the heart, testing the leads, securing the pacemaker generator, and closing the incision. Complications can include bleeding, infection, and lead issues.

1. Management of a patient with Pacemaker
Prepared by
Salman Habeeb

2. What is a pacemaker?
• A pacemaker (or artificial pacemaker) is a
medical device which uses electrical impulses,
delivered by electrodes contracting the heart
muscles, to regulate the beating of the heart

3. History of pacemakers
• In 1838 Carlo Matteucci a Professor of Physics
at the University of Pisa - discovered that an
electric current accompanies each heartbeat.

4. • 1926- Dr. Albert Hyman created an
electromechanical instrument which many
believe may be the first successful pacemaker

5. • 1950 a Canadian electrical engineer - John
Hopps paired with Dr. Wilfred Bigelow
• The new pacemaker was a great advancement
but still had some shortcomings like large and
heavy
• The externally placed electrode sent electric
impulses great deal of pain for the patient.

6. • 1951-Dr. Paul Zoll a cardiologist from Boston
The pacemaker used modern transistors but
still was large, heavy and relied on AC power.
• In 1957 - A part time TV repairmen Earl
Bakken.,developed a smaller pacemaker that
could be worn around the neck
• Less pain for patients,he leads were surgically
attached to the outside of the myocardium.

7. • In 1956 bekkan read an article related to
amplification of sound
• He started to work on amplification of battery
for the power to pacemaker

8. • Created pacemaker with mercury battery
that supplied 9.4 volts and co founded
medtronics company

9. • After these period with the size of
pacemakers and the short battery life,
the idea of implanting a pacemaker into
a patient was unthinkable
• Greatbatch -an electrical engineer
founded a implanting pacemaker
• Greatbatch joined with medtronics and
created litium iodine battery that still
using in pacemakers

10. • In 1958 Dr. Dr. Ake Senning and team done
first succesful pacemaker implantation to a
patient named “Arne larsson with stoke –
adam syndrome

11. • There was some problems with pacemakers so
he received 5 different lead systems and 22
pulse generators of 11 different models in his
lifetime
• lived to be 86 years old
dying in December 28
2001 of cancer.

12. • 1960s – demand pacemaker was developed
• 1970- nuclear powred pacemaker battery
developed (plutonium) can last upto 20 years
but due to radiation exposure and other
complication withdrawn from industry

13. Types
• Implantable pulse generators with
endocardial or myocardial electrodes for long-
term or permanent use( permenant
pacemakers)

14. 2
• External, miniaturized, transistorized, patient
portable, battery-powered, pulse generators
with exteriorized electrodes for temporary
transvenous endocardial or transthoracic
myocardial pacing. (temporary pacemakers)

15. • 3. Console battery- or AC-powered
cardiovertors, defibrillators, or monitors with
high-current external transcutaneous for
temporary pacing in asynchronous or demand
modes, with manual or triggered initiation of
pacing

16. what is a permenant pacemaker
• A permenant pacemaker is an electronic
device, approximately the size of a pocket
watch, that senses intrinsic heart rhythms and
provides electrical stimulation when indicated

17. Indications
(ACC/AHA/HRS Guidelines)
• Class I - The procedure should be performed
• Class IIa – It is reasonable to perform the
procedure, but additional studies with focused
objectives are needed
• Class IIb - The procedure may be considered, but
additional studies with broad objectives are
needed
• Class III - The procedure should not be
performed; it is not helpful and may be harmful

18. Class I indications
• Sinus node dysfunction
• Acquired atrioventricular block in adults
• Chronic bifascicular block
• After acute myocardial infarction
• Hypersensitive carotid sinus syndrome and
neurocardiogenic syncope
• After cardiac transplantation
• Pacing to prevent tachycardia
• Patients with congenital heart disease

19. Class IIa indications
• Sinus node dysfunction
• Acquired atrioventricular block in adults
• Chronic bifascicular block
• Hypersensitive carotid sinus syndrome and
neurocardiogenic syncope
• Patients with congenital heart disease
• Pacing to prevent tachycardia
• Permanent pacemakers that automatically
detect and pace to terminate tachycardia

20. Class IIb indications
• Sinus node dysfunction
• Acquired atrioventricular block in adults
• Chronic bifascicular block
• After acute myocardial infarction
• Hypersensitive carotid sinus syndrome and
neurocardiogenic syncope
• After cardiac transplantation
• Pacing to prevent tachycardia
• Patients with congenital heart disease

21. Class III indications
• Asymptomatic first-degree AV block.
• Asymptomatic type I second-degree AV block
at the supra-His (AV node) level or that which
is not known to be intra- or infra-Hisian.
• AV block that is expected to resolve and is
unlikely to recur(e.g., drug toxicity, Lyme
disease, or transient increases in vagal tone or
during hypoxia in sleep apnea syndrome in the
absence of symptoms

22. Parts of a pacemaker system

24. Pulse generator
• Lithium batteries lasting 6 years or more are
used in most pacemakers.
• Nuclear powered pacemakers (Plutonium238
source) can last 20 years or more.
• It controls energy output, heart rate and
pacing node.

25. Energy output
• It refers to the intensity of the electrical
impulse delivered by the pulse generator to
the myocardium.
• Measured in milliampers(M.A)
• A setting of 1.5 MA usually is sufficient to
cause depolarization

26. Heart rate
• heart rate is usually set at70-80 beats/minute

27. PACEMAKER LEADS
• Pacemaker leads are electrical conductors
(wires), covered with insulation. They transmit
the electrical impulses from the pulse
generator to the heart, and from the heart to
the pulse generator.
• They will attach to the heart in different ways

28. Active fixation
• in active fixation a screw (also known as a
helix) is used to fix the lead to the heart.

29. Passive fixation
• In passive fixation the lead has tines ,which
are designed to engage the trabeculae on the
inner surface of the heart

30. APPROACHES OF PACING

31. Single Chamber pacing
• With this device, 1 pacing lead is implanted in
the right atrium or ventricle

32. Double chamber pacing
With this device, 2 pacing leads are implanted
(1 in the right ventricle and 1 in the right
atrium); this is the most common type of
implanted pacemaker

33. cardiac resynchronization therapy
[CRT])
• Biventricular pacing -With this approach, in
addition to single- or dual-chamber right heart
pacing leads, a lead is advanced to the
coronary sinus for left ventricular epicardial
pacing.

34. CONCEPTUAL BUILDING BLOCKS OF
PACEMAKER FUNCTION
• Pacing
refers to the regular output of electrical
current, for the purpose of depolarizing the
cardiac tissue in the immediate vicinity of the
lead, with resulting propagation of a wave of
depolarization throughout that chamber.

35. Sensing
• Sensing describes the response of a
pacemaker to intrinsic heartbeats
• During heartbeat The heart’s intrinsic
electrical activity (i.e. the P wave or QRS
complex) transmits a small electrical current
(a few millivolts), through the pacemaker
leads, to the pulse generator. This current can
be registered or sensed by the pacemaker
circuitry

36. • sensing can be unipolar or bipolar
Unipolar sensing detects electrical activity
occurring between the tip of the lead, and the
metal shell of the pulse generator
Bipolar sensing detects the intrinsic
electrical activity occurring between the tip
electrode and the ring electrode of the lead

37. • The sensitivity setting is measured in millivolts
and is initially set at about 2 to 5 mV
• If the sensitivity is set very high the generator
will Fail to sense the heart’s intrinsic impulses
it is called undersensing
• if the sensitivity set low, that allowing the
generator to detect beats that occur at lower
millivolt levels and detecting beats that are
not actually occurring it is called oversensing

38. Inhibition of output
A pacemaker can be programmed to inhibit
pacing if it senses intrinsic activity, or it can be
programmed to ignore intrinsic activity and
deliver a pacing stimulus anyway. If a pacemaker
is set so that it can be inhibited by intrinsic beats

39. Pacing Threshold
• The threshold is the minimum amount of
energy the pacemaker sends down the lead
to initiate a heart beat.

40. Capture
• Electrical capture, is Cardiac depolarization
and resultant contraction (atrial or
ventricular) - Caused by pacemaker stimulus,
is detected by examining an electrocardiogram
• Capture is both an electrical and a mechanical
event
• Electrical capture –spike in ECG
• Mechanical capture-pulse

41. Rate response
• Most of the pacemekers available today are
rate responsive ,it have various sensors that
will active while patient during activities and
adjust the rate .

42. Triggered pacing
• This type of pacing is most often used in dual
chamber pacemakers.
• Dual chamber pacemakers can be
programmed to sense activity in one chamber
(usually the atrium) and deliver a pacing
stimulus in the other chamber (usually the
ventricle) after a certain time delay. This is
known as triggered pacing

43. PACING MODES
• North American Society for Pacing and
Electrophysiology, and the British Pacing and
Electrophysiology Group developed a standard
code (the NASPE/BPEG Generic Code, known
as the NBG Code)

44. Position and Letters
• Position 1: chamber being paced
• V = ventricle
• A = atrium
• D = atrium and ventricle (dual)
• O = no pacing.

45. • Position 2: chamber being sensed
• V = ventricle
• A = atrium
• D = atrium and ventricle (dual)
• O = no sensing

46. Position 3: pacing response to a
sensed beat
• I = inhibited
• T D = inhibited or triggered (dual) depending
on the chamber
• O = neither inhibited or triggered.

47. • Position 4: rate response or absence
• R = rate responsive
• O = absence of rate response. (But this is
usually just omitted)

48. Example
• VVI
• Position 1 (v)-indicates that it will pace only in
the ventricle.
• Position 2 – V indicates that it senses intrinsic
heartbeats only in the ventricle.
• Position 3 – I indicates that the response to a
sensed heartbeat is inhibition of ventricular
pacing.
• Position 4 – blank, indicating that it is not rate
responsive

49. PROCEDURE
• Venous assess
• subclavian vein, the cephalic vein, or (rarely)
the internal jugular vein or the femoral vein
are selected.
• subclavian vein is typically accessed at the
junction of the first rib and the clavicle

50. • a guide wire is advanced through the access
needle, and the tip of the guide wire is
positioned in the right atrium or the venacaval
area under fluoroscopy.
• The needle is then withdrawn, leaving the
guide wire in place

51. 2.Creation of pocket
• A 1.5- to 2-inch incision is made in the
infraclavicular area parallel to the middle third
of the clavicle, and a subcutaneous pocket is
created with sharp and blunt dissection where
the pacemaker generator will be implanted

52. 3.Placement of lead(s)
• Over the guide wire, a special peel-away sheath
and dilator are advanced
• The guide wire and dilator are withdrawn, leaving
the sheath in place
• A stylet (a thin wire) is inserted inside the center
channel of the pacemaker lead to make it more
rigid, and the lead-stylet combination is then
inserted into the sheath and advanced under
fluoroscopy to the appropriate heart chamber.

53. • ventricular lead is positioned before the
atrial lead to prevent its dislodgment
• Once correct lead positioning is confirmed,
the lead is affixed to the endocardium either
passively with tines (like a grappling hook) or
actively via a helical screw located at the tip
• Once the lead is secured in position, the
introducing sheath is carefully peeled away,
leaving the lead in place

54. • After the pacing lead stylet is removed, pacing
and sensing thresholds and lead impedances are
measured with a pacing system analyzer, and
pacing is performed at 10 V to make sure that it
is not causing diaphragmatic stimulation
• If a second lead is indicated, it is positioned in the
right atrium via a second sheath, with the lead tip
typically positioned in the right atrial appendage

55. Positioning of pulse generator
• When the leads have been properly
positioned and tested and sutured to the
underlying tissue, the pacemaker pocket is
irrigated with antimicrobial solution, and the
pulse generator is connected securely to the
leads.

56. Completion and closure
• The incision is closed in layers with absorbable
sutures and adhesive strips. Sterile dressing is
applied to the incision surface. An arm
restraint or immobilizer is applied to the
unilateral arm for 12-24 hours to limit
movement

57. Complications
• Access-related complications
Bleeding
• Hematoma
• Phlebitis or thrombophlebitis of the vein
• Local infection
• Arterial injury or puncture
• Hemothorax
• Pneumothorax

58. • Catheter-related thrombosis (which may lead to
pulmonary embolism)
• Air embolism
• Dysrhythmias
• Atrial wall puncture from guide wire (which may
lead to pericardial tamponade)
• Lost guide wire
• Anaphylaxis
• Chylothorax (possible with left-side lead insertion

59. • Pocket-related complications
• Lead-related complications
• Pacemaker generator–related complications

60. Cardiac Resynchronization Therapy
• Cardiac resynchronization therapy (CRT), also
referred to as biventricular pacing or multisite
ventricular pacing, is a component of modern
heart failure therapy for qualified patients
• there is a coronary sinus lead for left
ventricular epicardial pacing is present
• This reduce ventricular dyssynchrony that is
frequently present in patients with ventricular
dilatation or conduction system defect.

61. Who need CRT
• a left ventricular ejection fraction less than
35%,
• a QRS duration longer than 120 msec, sinus
rhythm,
• New York Heart Association (NYHA) functional
class III or ambulatory class IV heart failure
symptoms with optimal medical therapy.

62. BENEFITS TO HEART FAILURE PATIENTS
• Reduction in ventricular electromechanical delay
• Improved ventricular function
• Reduced metabolic costs
• Improved functional mitral regurgitation
• Favorable remodeling
• Reduction of cardiac chamber dimensions
• Improved exercise capacity

63. PROCEDURE
• CRT requires left ventricular lateral wall
pacing, which is achieved by placement of an
epicardial lead via the coronary sinus
• A guide wire is inserted through the catheter
positioned in the coronary sinus and
maneuvered to the target venous branch
• The guide wire and guide catheter are
withdrawn, leaving the coronary sinus lead in
place.

64. Implantable Cardioverter-
Defibrillator( ICD)
• An implantable cardioverter-defibrillator (ICD)
is a specialized device designed to directly
treat a cardiac tachydysrhythmia
• ICDs have revolutionized the treatment of
patients at risk for sudden cardiac death due
to ventricular tachyarrhythmias

66. Indications for ICD
• secondary prophylaxis
• primary prophylaxis.

67. Secondary prophylaxis
• An ICD is recommended as initial therapy in
survivors of cardiac arrest due to VF or
hemodynamically unstable VT.

68. Primary prophylaxis

69. TEMPORARY PACEMAKERS
• Temporary cardiac pacing involves electrical
cardiac stimulation to treat a bradyarrhythmia
or tachyarrhythmia until it resolves or until
long-term therapy can be initiated

70. TYPES
-Invasive approach
• Transvenous pacing
• Epicardial pacing
– Non invasive
• Transcutaneous pacing

71. • Medtronic’s Single Chamber Temporary
External Pacemaker
• Medtronic’s Dual chamber Temporary External
Pacemaker Model

72. Connection
• EITHER unipolar or bipolar electrode wires
• OUT Of the several methods for temporary
pacing of the heart (transcutaneous,
transvenous, transesophageal, transthoracic,
and epicardial), transvenous and
transcutaneous cardiac pacing are the most
commonly used

73. TRANSVENOUS PACING
• Transvenous cardiac pacing can be used as a
bridge to permanent pacing when permanent
pacing is not available, when the pacing need
is only temporary, or when further evaluation
is required

74. INDICATIONS
• Injury to the SA node or other parts of the conduction
system after cardiac Chest and cardiac trauma
associated with either temporary SA node or AV node
dysfunction
• Metabolic and electrolyte derangements
(eg, hyperkalemia)
• Drug-induced bradyarrhythmia (eg, digitalis toxicity); if
treatment with the drug must be continued and there
is no alternative, permanent pacing should be
considered
• Other diseases (eg, Lyme disease, bacterial
endocarditis) that may be associated with temporary
damage to the SA node or the AV node

75. PROCEDURE
• Venous access
Local anesthesia
internal jugular and subclavian common
sites

76. Other sites
• Central Venous Access, Internal Jugular Vein,
Anterior Approach, Tunneled
• Central Venous Access, Internal Jugular Vein,
Posterior Approach
• Central Venous Access, Subclavian Vein,
Subclavian Approach
• Central Venous Access, Subclavian Vein,
Supraclavicular Approach
• Femoral Central Venous Access

77. Placement of pacing lead
• a semirigid pacing lead may be used
• The lead is advanced until it reaches the RA
• To reach the RV, the catheter is passed
through the tricuspid valve; this may be
accomplished more easily if the clinician forms
a loop in the atrium and rotates the catheter

78. • When the lead is in place, it is connected to
the external generator, and the appropriate
mode is selected
• In an emergency, the highest output should be
tried first; it should then be gradually reduced
until the capture is lost

79. If the situation is not an emergency,
• the rate is set 10-20 beats/min above the
intrinsic heart rate
• the output is initially set very low and then
gradually increased until capture occurs
• The output should be set to a value at least 2-
3 times higher than the threshold to ensure a
safe margin for any change that occurs in the
capture threshold, which is usually less than 1
mA

80. • To check the sensing threshold (if it is needed
in the demand pacing mode), the pacing rate
should be set lower than the intrinsic heart
rate
• The value of the sensing threshold should
then be gradually increased until the
pacemaker fails to sense the intrinsic activity
and consequently begins firing

81. • The sensing threshold is usually more than 5
mV in the ventricle and is much lower in the
atrium
• Confirmation of pacing lead position
ECG,chest X ray

82. ECG changes
• A paced QRS should exhibit left bundle-branch
block (LBBB) morphology because the lead is
located in the right ventricle
• If the pacing lead is in the right ventricular
outflow tract, the paced QRS complexes show
LBBB morphology and an inferior axis (which
might also be rightward)

83. • A pacing lead in the coronary sinus will show
right bundle-branch block (RBBB) morphology
• Complications
Sequelae of venous access
Loss of capture and undersensing
Oversensing
Ventricular arrhythmia
Myocardial perforation

84. EPICARDIAL PACING
• This type of pacing is initiated after cardiac
surgery
• Indications for temporary epicardial pacing
The main indication for insertion of
epicardial pacing wires is perioperative
arrhythmias

85. • bradycardia,
• nodal or junctional arrhythmias
• atrioventricular block

86. procedure
• Commonly single or double set of electrodes
• Each elctrode contains positive and
negative(smaller)
• Ventricular-left of sternum
• Atrium – right to sternum

87. Insertion of ventricular pacing wires
• Left ventricular electrodes may be placed in
the apex just to the left of the distal left
anterior descending artery or along the
obtuse margin
• Wires should be inserted into the bare
muscular portion of the ventricle to ensure
adequate myocardial contact

88. Removal of pacing wires
• Pacing wires are usually removed on the
fourth postoperative day

89. Complications
• Bleeding from the site of insertion
• Dislodgement and fracture of pacing wires
• ventricular arrhythmias

90. TRANSCUTANEOUS PACING
• also called external pacing
• accomplished by delivering pulses of electric
current through the patient's chest, which
stimulates the heart to contract

91. Indications
• It can be used until permanent pacing
becomes available
• is indicated primarily for the treatment of
bradycardia and various types of heart block,
intermittent overdrive pacing can also be used
as an antitachycardic treatment for various
atrial and ventricular tachycardias (eg,
postoperative atrial flutter and monomorphic
ventricular tachycardia)

92. • It is the pacing method of choice in patients
who received thrombolytic therapy for acute
myocardial infarctionwhen the risk of
bleeding from surgical incisions is high.

93. PROCEDURE
• Patient Preparation
Anesthesia –patient may have pain so
sedation by midazolam is used
Positioning-
remove the hair
anterior electrode placed either over the
cardiac apex or at the position of lead V3

94. • posterior electrode, positive polarity, placed
inferior to the scapula or between the right
or left scapula and the spine

95. • Turn the pacemaker on, and choose the
pacing mode
• The demand mode is usually preferable and
should be used initially
• the pacing threshold is usually less than 80
mA

96. NURSING MANAGEMENT

97. HEALTH EDUCATION