Download Uses, Indications and Types of Pacemakers Available to

Pacemakers:
The Recommendations and
Guidelines for our patient
population today.
By: Michelle Miller OMSIII
Millcreek Hospital
May 31, 2006
Objectives and Learning Topics
• Recommendations for Pacemaker Therapy
• Types of Pacemakers
• The most appropriate Pacemakers for
each condition
• Contraindications and Warnings
Pace yourself for the Facts on
Pacemakers.
• First Pacemaker was implanted in 1958
• In the USA 300,000 people have pacemaker
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implants per year.
Worldwide 900,000 people have pacemaker
implants per year.
First Pacers were Fixed Rate Pacers today we
use Rate Responsive Pacemakers.
Most Conditions Requiring Pacers are
Bradyarrythmias/Tachyarrythmias.
Class Recommendations from the
ACC/AHA for Pacemaker Therapy
• Class I: Conditions for which there is
evidence and/or general agreement that a
given procedure or treatment is beneficial,
useful, and effective.
• Class II: Conditions for which there is
conflicting evidence and/or a divergence
of opinion about the usefulness/efficacy of
of a procedure or treatment.
Class Recommendations Continued
• Class IIa: Weight of evidence/opinion is in favor
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of usefulness/efficacy
Class IIb: Usefulness/ efficacy is less well
established by evidence/opinion
Class III: Conditions for which there is evidence
and/or general agreement that a procedure
/treatment is not useful/ effective and in some
cases may be harmful.
Levels of Evidence that support
recommendations of Pacemaker
Therapy
– Level A: Data derived from multiple randomized
clinical trials involving a large number of individuals
– Level B: Data derived from a limited number of trials
involving comparatively small numbers of patients or
from well-designed data analysis of nonrandomized
studies or observational data registries
– Level C: Consensus of expert opinion was the
primary source of recommendation
Overview of “A BAD BEAT STORY”
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AV block
Bifascicular and trifascicular block
AV block associated with myocardial infarction
Sinus node dysfunction
Hypersensitive Carotid Sinus Syndrome (CSS)
Vasovagal Syncope (VVS)
Tachyarrhythmias/Prevention of Tachycardias
Hypertrophic Cardiomyopathy
Pacing after cardiac transplantation
Children and adolescents with Congenital Heart
Conditions.
Symptomatic Indications for Pacer
Therapy
• Syncope or pre-syncope
• Dizziness
• Congestive heart failure
• Mental confusion
• Palpitations
• Shortness of breath
• Exercise intolerance
Recommendations for Pacemaker
Therapy In AV Block
• Class I:
1.)Third Degree Block and Type II second-degree AV
block at any anatomic level, associated with any
one of the following conditions:
-Bradycardia with symptoms (C)
-Arrhythmias and other medical conditions that
require drugs that result in symptomatic
bradycardia. (C)
-documented periods of asystole greater than or
equal to 3.0 seconds or any escape rate less than
40 BPM in awake or symptom free pts. (B,C)
Continued AV Block Pacemaker
Recommendations
Class I: Third Degree Block and Type II seconddegree AV block at any anatomic level,
associated with any one of the following
conditions:
-After catheter ablation of the AV junction. (B,C)
-Postoperative AV block that isn’t expected to
resolve. (C)
-neuromuscular diseases with AV block, such as
myotonic muscular dystrophy, Kearns-Sayre
syndrome, Erb’s dystrophy, with or without
symptoms, because there may be unpredictable
progression of AV conduction diseases. (B)
AV Block Pacemaker
Recommendations
• Class I :
2.)Second Degree AV Block regardless of type or site in
the presence of symptomatic bradycardia. (B)
• Class IIa:
• 1.Asymptomatic third degree AV block. (B,C)
• 2.Asymptomatic type II second-degree AV block occurs
with a narrow QRS. (B)
• 3.Asymptomatic type I second-degree AV block at intraor infra- His levels found at electrophysiologic study
performed for other indications. (B)
• 4.First or second degree AV block with symptoms of
pacemaker syndrome. (B)
Recommendations for Pacemaker
Therapy with Bifascicular and
trifascicular block.
• Class I:
1. Intermittent Third Degree AV Block. (B)
2. Type II Second Degree AV Block (B)
3.Alternating Bundle Branch Block (C)
Class IIA:
1.Syncope not to be due to AV block when other likely
causes have been excluded. (B)
2.Incidental findings at electrophysiologic study of
markedly prolonged HV interval (greater than or equal to
100 milliseconds.) (B)
3. Incidental finding at electrophysiological study of pacing
induced infra-His block that is not physiologic (B)
Recommendations for Permanent
Pacing S/P Acute MI
• Class I:
1. Persistent second-degree AV block in the His
2.
3.
Purkinje system with bilateral bundle-branch
block or third degree AV block within or below
the His-Purkinje system s/p MI. (B)
Transient advanced (second or third degree )
infranodal AV block and associated bundle
branch block. (Use Electrophysiology for exact
site.) (B)
Persistent and symptomatic 2nd and 3rd Degree
AV Block. (C)
Recommendations for Permanent
Pacing in Sinus Node Dysfunction
• Class I:
1.Sinus node dysfunction with documented symptomatic
bradycardia, including frequent sinus pauses that
produce symptoms. (C)
2.Symptomatic chronotropic incompetence (C)
Class IIA: 1. Sinus Node dysfunction occurring
spontaneously or as a result of necessary drug therapy
with heart rate less then 40 BPM when a clear
association between significant symptoms consistent
with bradycardia and it hasn’t been documented.(C)
2. Syncope of unexplained origin when major abnormalities
of sinus node function are discovered or provoked in
electrophysiologic studies.(C)
Recommendations for Pacing that
detect and pace to terminate
tachycardias.
• Class I: NONE
• Class IIa: Symptomatic recurrent SVT that
is reproducibly terminated by pacing in the
unlikely event that catheter ablation and
/or drugs fail to control the arrhythmia or
produce intolerable side effects. (C)
Pacing Recommendations to
Prevent Tachycardia
• Class I: Sustained paused – dependent VT,
with or without prolonged QT, in which the
efficacy of pacing is thoroughly
documented. (C)
• Class IIA: High risk patients with
congenital long QT syndrome. (C)
Recommendations for Pacing
Neurocardiogenic Syncope
(ex.Hypersensitive Carotid Sinus; Vasovagal
Syncope)
• Class I: Recurrent syncope caused by carotid sinus
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stimulation; minimal carotid sinus pressure induces
ventricular asystole of more than 3 seconds duration in
the absence of any medication that depresses the sinus
node or AV conduction. (C)
Class IIA: 1. Recurrent syncope without clear,
provocative events and with a hypersensitive
cardioinhibitory response. (C)
2. Significantly symptomatic and recurrent
neurocardiogenic syncope associated with bradycardia
documented spontaneously or at the time of the tilt table
testing. (B)
Recommendations for hypertrophic
cardiomyopathy
• Class I: Use class I indications for sinus
node dysfunction or AV block.(C)
Recommedations s/p Cardiac
Transplant
• Class I: Symptomatic
bradyarrhythmias/chronotropic
incompetence not expected to resolve and
other Class I indications for permanent
pacing.(C)
Recommendations for pacing in Children,
Adolescents and Patients with Congenital
heart disease.
• Class I:
1. Advanced 2nd or 3rd degree AV Block associated with
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bradycardia, ventricular dysfunction, or low cardiac
output. (C)
Sinus Node Dysfunction with correlation of symptoms
during age-inappropriate bradycardia. The definition of
bradycardia varies with the patient’s age and expected
Heart Rate. (B)
Postoperative advanced 2nd and 3rd degree AV block
that isn’t expected to resolve or persists at least 7 days
after surgery. (B, C)
Congenital 3rd degree AV Block in the infant with a
ventricular rate <50 BPM or with congenital heart
disease and ventricular rate < 70 BPM. (B,C)
Recommendations for pacing in Children,
Adolescents and Patients with Congenital
heart disease continued….
• 5. Congenital third degree AV Block with a
wide QRS escape rhythm, complex
ventricular ectopy or ventricular
dysfunction. (B)
• 6. Sustained pause-dependent VT, with or
without prolonged QT, in which the
efficacy of pacing is thoroughly
documented. (B)
Recommendations for pacing in Children,
Adolescents and Patients with Congenital
heart disease continued….
• Class IIa:
1.Bradycardia-tachycardia syndrome with the need for long-term
antiarrhythmic treatment other than digitalis. (C)
2.Congenital 3rd Degree AV block beyond the first year of life
with an average heart rate less than 50 bpm, abrupt pauses in
ventricular rate that are two or three times the basic cycle
lenghth, or associated with symptoms due to chronotropic
incompetence. (B)
3. Long-QT sydrome with 2:1 AV or 3rd Degree AV Block. (B)
4. Asymptomatic sinus bradycardia in the child with complex
congenital heart disease with resting heart rate less than 40
bpm or pauses in ventricular rate more than 3 seconds. (C)
5.Patients with Congenital Heart Disease and impaired
hemodynamics due to sinus bradycardia or loss of AV
synchrony. (c)
Types of Pacemakers
• Single Chamber Pacemaker:
1. Uses 1 lead in the right atria (VDD) OR
2. Uses 1 lead in the right ventricle (VVI)
• Dual Chamber Pacemaker (DDD):
1. A lead in both the Right Atria and Right
Ventricle.
• Biventricular Pacemaker (DDDR) / (VAT):
1. Uses three leads: One in the right atrium, one in
the right ventricle and one in the left ventricle.
“Fantastic 4” Factors influenced by
the Pacemaker
• Heart rate increase
• Stroke volume maximization
• Atrial based pacing
• Normal ventricular activation sequence
Rate Responsive Pacing in the
presence of Respiratory Function.
• Minute ventilation can
be measured by
measuring the
changes in electrical
impedance across the
chest cavity to
calculate changes in
lung volume over time
How a Rate Responsive Device
Works!
Pulse Generator
Circuitry
Piezoelectric crystal
Battery
The Leads
Cathode
Anode
The Crystal Senses mechanical activity from the pacer and signals electrical activity
Transvenous Leads
Passive Fixation Lead tines are lodged
Into the Trabeculae
Active Fixation Leads are extended
into the endocardium of the Heart,
this allows for them to position
anywhere in the heart.
Myocardial and Epicardial leads
Leads are applied directly to the
heart.
They are fixed to the wall by:
1.Epicardial Stab in
2.Myocardial Screw in
3.Suture on
Arrythmias that require Single
Chamber Atrial Pacing
• Sinus Node Dysfunction with NML AV and
Intraventricular Conducting System.
• Paroxysmal Atrial Fibrillation.
• ***Dual Chamber Pacing occurs for Sinus
Node Dysfunction and PAF with there is
abnormal AV conduction seen of EP
studies.
Arrhythmias that require Dual
Chamber Pacing
• 1. Sinus Sick Syndrome
• 2.Chronic Second Degree Type II heart
block.
• 3. Chronic Third Degree Heart block
• 4. Recurrent Adams Stokes Syndrome.
• 5. Symptomatic Bilateral Bundle Branch
Block when tachyarrhythmias and other
Block causes are ruled out.
Arrhythmias that require Single
Chamber Ventricular Pacing
1. Significant bradycardia and Nml Sinus Rhythm
with rare episodes of AV Block or Sinus Arrest.
Arrhythmias that require Biventricular
Pacing:
1. Chronic Atrial Fibrillation Treating Advanced
CHF in pts with major intraventricular
conduction defects predominantly LBBB.
Rate Responsive Device:
1. Chronotropic Incompetence.
Contraindications For…
• 1. Dual Chamber Pacers and single chamber pacers: Not
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indicated for Chronic Atrial Flutter/Fibrillation or Silent
Atria, these particular pacers show no benefit in txt of
the conditions.
2. Single Chamber Ventricular Pacer: relatively
contraindicated in pt demonstrating “Pacemaker
Syndrome”.
3. Single Chamber Atrial Pacing: relatively
Contraindicated in pt having AV conduction compromise.
4.Rate Modulated Pacing: may be inappropriate for pt
who experience angina or other symptoms of myocardial
dysfunction at higher sensor driven rates.
Warnings For Pacemaker Pts.
• To prevent damage to the
electrode/tissue interface:
1. Avoid Sources of Magnetic and
Electromagnetic Radiation.
-MRI
-Hydraulic Shock wave lithotripsy
-No therapeutic ultrasounds within 6
inches of the pacemaker.
References
• Gregoratos, Gabriel et al. ACC/AHA/NASPE 2002 Guideline
Updatefor Implantation of Cardiac Pacemakers and Antiarrhythmia
Devices.
http://www.acc.org.clinical/guidelines/pacemaker/I_indications.htm
2002.
• Pacemaker Implantation.
http://heartpoint.com/pacemakers.html#anchor510098
• How do Pacemakers Work? British Heart Foundation.
www.bhf.org.uk/hearthealth/index.asp?secID=1&secondlevel=79&th
irdlevel=475&artID1632
• Pacemakers. The Cleveland Clinic Heart and Vascular Institute.
http://www.clevelandclinic.org/heartcenter/pub/tests/procedures/pa
cemakers.htm
Review Questions
1.
A 65 yo white female presents in the ER s/p syncopal episode.
She states this has happened “a couple times” before. Her EKG
shows atrial fibrillation with LBBB. On physical exam she has no
neurologic deficits, her heart is irregularly, irregular and her lungs
are CTA. Dr. D’Amico is consulted and determines that this patient
would benefit from a pacemaker. Being the astute
resident/student that you are you determine the best pacer
therapy for this particular patient’s condition would be:
A.
B.
C.
D.
E.
Fixed, Single Chamber Ventricular Pacemaker
Rate Modulated, Single Chamber Ventricular Pacemaker
Fixed, Biventricular Pacemaker
Rate Modulated, Biventricular Pacemaker
Rate Modulated, Dual Chamber Pacemaker
Review Questions
A 55 yo hispanic male presents with his chief
complaint of SOB and intermittent dizziness
times 1 month. His O2 Sats at 100% on 2L NC.
On physical exam there are no neurologic
deficits, bradycardia, Lungs are CTA. CT was
negative, but his EKG had some interesting
finding the PR interval was fixed at .24 seconds
and there is one dropped QRS complex. With a
ratio being 2 PR intervals to 1 QRS.
This type of arrhythmia is:
A.Second Degree Type one AV Block (Wenkebach)
B.Second Degree Type two AV Block
C.Second Degree Type two Advanced AV Block
D.Third Degree AV Block
Review Questions
Using the previous questions arrhythmia,
does this pt. qualify for pacemaker
therapy according to the
recommendation guidelines by the ACC
and AHA?
A. YES
B. NO