Pacing and Device Jargon Made Simple. Dr Jonathan Timperley MB ChB MD FRCP Consultant Cardiologist Northampton General Hospital
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1 Pacing and Device Jargon Made Simple Dr Jonathan Timperley MB ChB MD FRCP Consultant Cardiologist Northampton General Hospital
2 Disclosure Dr Jonathan Timperley Honorarium from Bayer
3
4 Arne Larson ( )
5 Pacing Lead Terminals
6 Unipolar Single tip electrode (cathode) Generator acts as anode Increased size of pacing artifact on ECG More susceptible to over sensing of non-cardiac signals Myopotentials EMI
7 Bipolar Tip electrode (cathode) and ring electrode (anode) If device allows can be programmed unipolar Reduced size of pacing artefact on ECG
8 WARNING At pulse generator replacement CHECK: Is the RV lead unipolar? Is the patient pacing dependent? CAN THE NEW DEVICE PACE UNIPOLAR OUT OF THE BOX????? (NOT ALL CAN)
9 Unipolarisation
10 DF4 and DF1
11 DF1 and DF4 Positives DF4 Smaller volume of leads in pocket Reduced risk of wrong lead into wrong port DF1 Can add azygos coil or array Can add new pace-sense IS-1 lead
12 Sensitivity
13 Sensitivity LESS SENSITIVITY = HIGHER NUMBER OF SENSITIVITY
14 Threshold, Output, Pulse Width, Rheobase
15 Strength-Duration Curve
16
17 Pacemaker Modes First Letter (PACED) Second Letter (SENSED) Third letter (ACTION WHEN EVENT SENSED) Fourth Letter ( IF PRESENT PRESENCE OF RATE RESPONSIVENESS) Fifth Letter (IF PRESENT INDICATES MULTISITE PACING) S Single A Atrial V Ventricular D Dual S Single A Atrial V Ventricular D Dual I Inhibited T Triggered D Dual (I and/or T) O No action R Rate response present A Atrial V Ventricular D Dual O Nil
18 VOO Asynchronous, competitive, magnent mode Risk of R-on-T Useful with diathermy interference
19 VVI After programmable VRB, LRI then stimulus UNLESS sensed event in that time
20 DDI Non-P synchronous pacing with dual chamber sensing Useful fall back mode if sensed atrial arrhythmia (often with ICD pre AAIR-DDD)
21 VDD Option on device but usually used with VDD pacing lead Ensures AV synchrony where possible without RA lead
22 DDD Physiological pacing with A -V synchrony Programmable components LRI, AVI, PVARP, VRP, URI
23
24 Refractory and Blanking Periods Atrial Blanking Period Post Atrial Ventricular Blanking Period Atrial Refractory Period Sensed AV Interval Paced AV Interval Ventricular Refractory Period Post Ventricular Atrial Refractory Period Total Atrial Refractory Period
25 Ventricular Safety Pacing Function to prevent inhibition of V Pacing due to far-field sensing causing asystole Without VSP, sensed event in the V channel after PAVB but before end of pavi will inhibit V pace With VSP, sensed event after PAVB but BEFORE end of VSP interval leads to V pacing VSP shorter than AV delay VSP lead to shorter AV delay and ensure that if the cause is a VE that it occurs in the safe phase of the QRS and not the T wave
26 Ventricular Safety Period Off
27 Ventricular Safety Period On
28 Pacemaker Mediated Tachycardia PMT or Endless loop tachycardia DDD when V paced beat conducts retrograde through AVN to generate P wave Triggered by: VPC with retrograde conduction Loss of atrial capture Atrial oversensing inhibits A pave then retrograde AV conduction Far-field A sensing of the tail of the QRS
29 PMT
30 Termination of PMT Programme longer PVARP after VPC so that retrograde P is not sensed
31 Reduction in RV Pacing
32 AV Search Hysteresis
33 Safe-R, MVP, AAIR-DDD RV pacing avoidance Appropriate switching between AAIR & DDD
34 Fusion and Pseudo Important especially with CRT Pseudofusion COUNTED in BiV pacing percentage BUT NO BiV pacing
35 ICD Can deliver (ATP), defibrillation and pacing Subcutaneous ICD increasingly used for primary prevention and VF secondary prevention Effective therapy for VT by interrupting the re-entrant VT circuit Programming of should be tailored where possible
36 ATP
37 Myopotentials Very high frequency low amplitude signals Related to skeletal muscle and diaphragm Increased risk with integrated bipolar lead and unipolar leads
38 Pacing Inhibition
39 VF and Pacing Inhibition
40 Battery Indicators ERI Elective Replacement Indicator Need generator replacement within 2 months EOL End of life Pacemaker will not function completely May revert to VOO pacing If pacing dependent or ICD admit and consider admission for all others unless very early slot for replacement available
41 RV Leadless Technology
42 LV Leadless Technology
43
44
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