This document provides an overview of pacemakers and implantable cardioverter-defibrillators (ICDs), including indications, components, configurations, complications, and management. It discusses pacemaker and ICD malfunctions such as failure to pace or sense appropriately, inappropriate pacing rates, and increased shock frequencies. The document emphasizes that pacemaker/ICD malfunctions usually indicate lead problems or changes in the underlying cardiac condition, and stresses consulting cardiologists for device evaluation and potential reprogramming or reimplantation.

1. Approach to pt with pacemaker and ICDs Badar AlHamrashdi. EM OMSB R3

5. Nomenclature for pacemakers C= communicating O = none O = none O = none O = none D = dual (shock + pace) R=rate adaptive D = dual (A and V inhibited) D = dual D = dual S = shock M=multiprogrammable I = inhibited V=ventricle V=ventricle P = pacing P = simple T=triggered A = atrium A = atrium Antitachycardia Functions Programm-ability Sensing Response Chamber Sensed Chamber Paced Letter 5 Letter 4 Letter 3 Letter 2 Letter 1

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

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

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

13. Pacemaker Configurations AAI Indications Sick sinus syndrome in the absence of AV node disease or atrial fibrillation.

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

15. 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.

27. 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

40. An approach to the evaluation of ICD malfunction

44. Practice Strip#1

45. Practice Strip #2

46. Practice Strip #3

47. Practice Strip #4

48. Practice Strip #5

49. Practice Strip #6

50. Practice Strip #7

51. Practice Strip #8