11/21/18. EKG Pop Quiz. Michael Giocondo, MD Cardiac Electrophysiology Saint Luke s Cardiovascular Consultants
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1 EKG Pop Quiz Michael Giocondo, MD Cardiac Electrophysiology Saint Luke s Cardiovascular Consultants 1
2 Disclosures No financial relationships to disclose. EKG #1 75 y/o woman with a dual-chamber pacemaker implanted for SSS presents for her annual visit. Symptoms: None. Programming: DDDR bpm. 2
3 EKG #1: The Pacemaker Behavior Noted is Best Described as 1) Atrial pacing with capture. Normal device function. 2) Ventricular pacing with capture. Normal device function. 3) Atrial and ventricular pacing with capture. Normal device function. 4) No evidence of pacing. Normal device function. 5) No evidence of pacing. Abnormal device function. EKG #1: Explanation - This EKG demonstrates normal sinus rhythm at 84 bpm with no evidence of either atrial or ventricular pacing. - Normal pacemaker behavior in DDDR mode is to inhibit pacing if the intrinsic rhythm is above the lower rate limit. - This behavior limits battery usage by preventing unnecessary pacing. - In addition, preventing excess unneeded right ventricular pacing prevents development of a pacing-induced cardiomyopathy caused by dyssynchronous ventricular activation related to right ventricular-only pacing. 3
4 EKG #2 82 y/o man with a dual-chamber pacemaker implanted for CHB 10 years ago presents for an urgent visit due to symptoms of dyspnea. Programming: DDDR bpm. EKG #2 EKG Obtained 1 Year Prior 82 y/o man with a dual-chamber pacemaker implanted for CHB 10 years ago presents for an urgent visit due to symptoms of dyspnea. Programming: DDDR bpm. 4
5 EKG #2: The Pacemaker Behavior Noted is Best Described as 1) Atrial pacing with capture, normal device function 2) Ventricular pacing with capture, normal device function 3) Atrial and ventricular pacing with capture, normal device function 4) Abnormal device function EKG #2: Explanation - This EKG demonstrates sinus rhythm with asynchronous, nonphysiologic ventricular pacing at 65 bpm. - This behavior is normal for a pacemaker device that has reached elective replacement indicator (ERI), A.K.A. recommended replacement time (RRT) status. - The device reverts to VVI mode with ventricular pacing at a fixed rate without rate-response. - With pacing the ventricular only, device battery drain related to dual-chamber pacing is avoided. - Patients are often symptomatic with fatigue, dyspnea, and palpitations due to pacemaker syndrome. 5
6 EKG #3 77 y/o man with a dual-chamber pacemaker implanted for SSS presents for an annual visit. Symptoms: intermittent palpitations. Programming: DDDR bpm. EKG #3: The Pacemaker Behavior Noted is Best Described as 1) Atrial pacing with capture, normal device function 2) Ventricular pacing with capture, normal device function 3) Atrial and ventricular pacing with capture, normal device function 4) Abnormal device function 6
7 EKG #3: Explanation - This EKG demonstrates an atrial and ventricular paced rhythm with intermittent AV delay prolongation. - This pacemaker behavior is normal and is related to an an advanced algorithm that allows for extension of the atrioventricular delay in order to allow prolonged conduction through the native conduction system. - This algorithm provides back-up ventricular pacing triggered after the prolonged AV delay expires. - All pacemaker brands employ similar algorithms to prevent unnecessary RV pacing and to promote battery longevity. EKG #3: Explanation Note Variable Atrioventricular Delay 7
8 EKG #4 89 y/o woman with a dual-chamber pacemaker implanted for CHB post TAVR who presents for a routine visit. Symptoms: None. Programming: DDDR bpm. EKG #4 EKG Before Pacemaker Implant 89 y/o woman with a dual-chamber pacemaker implanted for CHB post TAVR who presents for a routine visit. Symptoms: None. Programming: DDDR bpm. 8
9 EKG #4 Compare Before and After QRS Complexes 89 y/o woman with a dual-chamber pacemaker implanted for CHB post TAVR who presents for a routine visit. Symptoms: None. Programming: DDDR bpm. EKG #4: The Pacemaker Behavior Noted is Best Described as 1) Atrial pacing with capture, normal device function Before Pacer After Pacer 2) Ventricular pacing with capture, normal device function 3) Atrial and ventricular pacing with capture, normal device function 4) Abnormal device function 9
10 EKG #4: Explanation EKG #4: Explanation - Atrial and ventricular pacing with capture is noted. - The unique feature noted here is the unusually narrow paced QRS complex of ## msec related to His bundle pacing. - His bundle pacing allows the pacing stimulus to directly enter the conduction system or its surrounding tissue in order to provide more physiologic pacing vs. right ventricular apical pacing. - This newer technique has been shown to decrease heart failure symptoms in relatively small research studies. - Large research studies comparing this technique to standard right ventricular apical pacing are being discussed. His Bundle Pacing: Lead Positioning RA His RV 10
11 EKG #5 71 y/o woman with a dual-chamber pacemaker implanted for CHB who presents for a urgent visit because of intermittent lightheadedness. Programming: DDDR bpm. EKG #5: The Pacemaker Behavior Noted is Best Described as 1) Atrial pacing with capture, normal device function 2) Ventricular pacing with capture, normal device function 3) Atrial and ventricular pacing with capture, normal device function 4) Abnormal device function 11
12 EKG #5: Explanation - The intermittent pauses noted are related to pacemaker sensing of electrical noise from a lead fracture. - Pacemakers are not readily able to differentiate lead noise from normal intrinsic cardiac electrical activity. - This patient required urgent pacemaker lead revision with addition of a new right ventricular lead. - Pacemaker lead fracture may also cause pacing output failure. This may be difficult to diagnose, so pacemaker-dependent patients with symptoms of lightheadedness, near-syncope or syncope should be thoroughly evaluated. - Lead impedance and threshold testing, pocket manipulation, isometric maneuvers, ambulatory monitoring, and chest x-ray. EKG #5: Explanation Electron Microscope View of Lead Fracture Grossly Fractured Pacemaker Lead Intracardiac EGM: Pacing Inhibition From Lead Noise 12
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