Pacemaker Basics

2. Conduction System of Heart

3. Pacemakers
Devices that deliver localised electrical
stimulation to cardiac tissue
Types
– Temporary / Permanent
– Epicardial / Endocardial
– Transvenous / Epicardial /Transcutaneous/
Esophageal
– Single chamber / Dual chamber

4. Indications
Symptomatic Sinus node dysfunction
Atrioventricular Block
– second- or third-degree
Bifascicular and Trifascicular Block
Neurocardiogenic Syncope
Hypersensitive Carotid Sinus Syndrome
Hypertrophic Cardiomyopathy
Left Ventricular Systolic Dysfunction
– Cardiac Resynchronization Therapy (CRT)
Hypertrophic Cardiomyopathy
Long QT Syndrome
Prevention and Termination of Tachyarrhythmias
– Anti Tachycardia Pacing (ATP)

5. The Four Parts of the Pacing System
The Pulse Generator
The lead(s)
The patient care system (“programmer” )
And the patient!

6. Pulse generator
Casing ( “can”)
– Titanium
Connector
Components
– Diodes, resistors, oscillator, microchips
Battery
– Lithium iodide

7. Lead system
Screw-in

8. Epicardial Lead
Fastened (sutured) to outside of heart
Requires open-chest procedure
Has corkscrew mechanism

9. The NBG Code
Position I II III IV V
Category Chamber(s) Chamber(s) Response to Rate Multisite
paced sensed sensing Modulation Pacing
Letters 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*

10. Implantation Lab
High quality fluoroscopy
Monitoring
– 12 channel ECG
– BP (invasive/non-invasive)
– SpO2
– Defibrillator
– Programmer
– Oxygen
– Suction
– Intubation
– Crash cart

11. Lab personnel
2 Cardiologists
– First operator (should have performed 70 implants)
– Assistant
2 Nurses
– Scrub nurse
– Monotoring nurse
Cathlab technologist
Anesthetist on- call

12. Pre-implant protocol
Thorough 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 clear
Type of pacing system – single / dual
Informed consent
Food is withheld for 6 to 8 hours
Intravenous line – Hydration
Heparin stopped 6 hrs
Antiplatelets stopped 5 days
International Normalized Ratio (INR)<1.2
Antibiotic prophylaxis is controversial
Mild pre-procedural sedation
Prepare nipple line to the angle of the jaw bilaterally

13. Approaches
The 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 pacing
Axillary Vein Approach
Cephalic Vein Approach
– almost no risk of pneumothorax or
hemothorax

14. Parameters

15. Post-procedure management
Electrocardiogram
Analgesics
Antibiotics
Limit motion of the ipsilateral upper extremity
for 1 week
Before discharge, the device is programmed

16. Complications

17. Complications

18. Advice on discharge
Carry ID card showing “PPI implant”
Avoid EMI
– Arc-welding machines, digital cell phones,
– Anti-theft alarms, metal detectors
MRI contraindicated
ECSWL
Radiation
DC cardioversion
RF ablation
Electro-cautery

19. Thank You