Permanent pacemaker

Supervisor:
dr Pipin Ardhianto SpJP(K), FIHA
PACEMAKER
 Devices that can be placed in your body, usually by surgery, to support the electrical
system in your heart.
 When intrinsic cardiac automaticity or conduction integrity fails, the electrical
excitability of cardiac tissue allows a small, external electrical stimulus to drive
myocytes to threshold  Pacemakers provide that external stimulus
1. Mulpuru SK, Madhavan M, et al. Cardiac Pacemakers: Function, Troubleshooting, and Management: Part 1 of a 2-Part Series. J Am Coll Cardiol. 2017;69(2):189–210.
1. Mulpuru SK, Madhavan M, et al. Cardiac Pacemakers: Function, Troubleshooting, and Management: Part 1 of a 2-Part Series. J Am Coll Cardiol. 2017;69(2):189–210.
IMPLANTABLE PACEMAKER CIRCUIT
Leads
 Implantable pulse generator IPG
(IPG):
 Battery
 Circuitry
 Connector(s)
 Leads or wires
 Cathode (negative
electrode)
 Anode (positive electrode)
 Body tissue

Anode
Cathode
THE PULSE GENERATOR
 Common battery compositions include:
 Lithium-Iodine
 Lithium silver vanadium oxide
with carbon monoflouride
 Starting battery voltage will vary
Circuitry
depending on composition
 Longevity
 Dependent on impedance and output
 Commonly ranges from 6-12 years Battery
PACEMAKER

 Pacing terjadi saat terdapat perbedaan potensial (voltage) diantara 2 electrode.

 Energi minimum yang dibutuhkan mendepolarisasi myocard disebut dengan
Stimulation Threshold.
 Stimulus yang dikirimkan dijabarkan dalam 2 karakteristik:
 Amplitudes (volts)
 Duration (miliseconds)
 Energi yang dibutuhkan untuk mempacing myokard tergantung dari pulse width dan
voltage yang deprogram dan di deliver melalui electrode.
 Ohm’s Law (V = IR)
 V = voltage
 I = current
 R = resistance
Pacemaker tipe dan mode
 Tipe:
 Endokardial pacing
 Epicardial pacing
 Cardiac resynchronization therapy (endo/epi)
 Alternative methods
 Conduction system pacing
 Leadless pacing
 Mode:
Mode
 DDD
− Standard dual-chamber pacing is used when the sinus node is intact, but AV conduction
impaired. Sinus activity is sensed and will trigger ventricular pacing following a
programmed AV delay (p-synchronous pacing).
 DDDR
− Rate response is added when sinus and AV nodal function are both abnormal
 VVI AND VVIR
− Ventricular-only pacing is used in patients with chronic atrial fibrillation, or infrequent
pauses or bradycardias. The potential for tracking atrial arrhythmias is eliminated.
Single-chamber pacemakers with leads in the ventricle can deliver these modes.
 AAIR
− This mode is reserved for isolated sinus node dysfunction with intact AV nodal
conduction. It avoids ventricular pacing and, when delivered by a single-chamber
pacemaker, eliminates the need for a lead that crosses the tricuspid valve.
1. Glikson M, Nielsen JC, et al. 2021
ESC Guidelines on cardiac pacing and
cardiac resynchronization therapy.
Eur Heart J. 2021;1–94.
 PACEMAKER NOMENCLATURE
I II III IV V
The first letter: The second The third letter: The fourth The fifth letter:
the chamber(s) letter: chamber RESPONSE to a letter: RATE multisite pacing
PACED in which sensed electric MODULATION
electrical activity signal
is SENSED
• A: Atrial • A, V, or D • T: Triggering of • R: Rate-response • A, V, or D
• V: Ventricular • O is used when pacing function (“physiologic”)
• D: Dual-chamber the pacemaker • I: Inhibition of pacing
(atrial and discharge is not pacing function • O: No
ventricular) dependent on • D: Dual response programmability
sensing (i.e. any or rate
spontaneous modulation
atrial or
ventricular
activity will
trigger a paced
ventricular
response)
THE 4TH LETTER: “R”
• “R” means “Rate response”
• Pacemaker will increase pacing rate in response to
exercise – if patient does not increase his own
rate
SINGLE CHAMBER SYSTEM
 One lead
 Atrium
 Ventricle (most common)
 May be used for patients in
chronic AF (VVI pacemaker) or
patients with sinus node
dysfunction and no history of AV
block (AAI pacemaker)
VVI AAI
Pacemaker Pacemaker
DUAL CHAMBER SYSTEM

 Two leads
 One lead implanted in the
atrium
 One lead implanted in
the ventricle
 Provides AV synchrony and
pacing support in both atrium
and ventricle if needed

DDD Pacemaker
TRIPLE CHAMBER SYSTEM

 Three Leads:
 Right Atrium
 Right Ventricle
 Left Ventricle (via the Coronary
Sinus vein)
 Most commonly called a Bi-
Ventricular Pacemaker but also
called Cardiac Resynchronization
Therapy (CRT–P)
 Paces both ventricles together to
“resynchronize” the beat
VVI EXAMPLE (60 BPM)

• Paces and Senses in the ventricle

• Timed from each QRS
• If it sees a sensed event, it will inhibit the next pace

Lower rate timer 1000 ms Lower rate timer 1000 ms

V V V V

P P S P
GENERAL TERMINOLOGY

LOWER RATE LIMIT (LRL)

The slowest rate of pacemaker stimulation. This is analogous to the
pacing interval, which is the time period in milliseconds between two
consecutive paced events in the same chamber without an intervening
sensed event.

UPPER RATE LIMIT (URL)

This is the fastest rate the pacemaker will stimulate the heart (i.e. the
maximum tracking rate if a dual chamber device; or the maximum
sensor rate if rate response is turned on).
SENSING

The ability of the CIED to detect intrinsic myocardial depolarization (i.E., The
potential difference between the lead’s cathodal and anodal electrodes)

Programming changes to adjust sensing:

Lowering the mV setting makes the device more sensitive (to pick up missing
signals)
Increasing the mV setting makes the device less sensitive (to avoid detecting
signals)
PACING THRESHOLD
The pacing threshold is the minimum required energy that consistently
triggers a depolarization of the paced chamber

Multiple factors including antiarrhythmic drug use, physical activity

level, posture, time of day, and comorbidity could all affect the pacing
threshold
COMPLICATIONS OF DEVICES
PACEMAKER MALFUNCTION
1) failure to pace the appropriate cardiac chamber:
• Output failure
• Capture failure
2) problem with detecting intracardiac signals:
• Undersensing
• Oversensing
3) pseudomalfunction:
• Crosstalk with resultant safety pacing
• Pacemaker-mediated tachycardia
• Sensor-induced tachycardia
• Runaway pacemaker
• Lead-displacement dysrhythmia
• Twiddler syndrome
OUTPUT FAILURE
A failure of output is suspected if the heart rate is
below the programmed lower rate of the pacemaker
and no pacer electrical output is noted on the
electrocardiogram (ECG)  pacing spikes are absent.

CAUSES :
• generally lead failure (lead fracture, lead
displacement)
• generator failure
• battery failure
• crosstalk inhibition
• oversensing
OUTPUT FAILURE
CAPTURE FAILURE
Capture failure occurs when the generated pacing stimulus does not initiate
myocardial depolarization.
On the surface ECG, pacing spikes are present, but they are not followed by a
QRS complex in the event of ventricular noncapture or by the lack of P waves
in the event of atrial noncapture

CAUSES :
• lead dislodgment
• low output
• lead maturation (inflammation or fibrosis at the electrode tip)
• lead or pacer failure (lead fracture, low pacing voltage, or elevated
myocardial pacing thresholds)
CAPTURE FAILURE
UNDERSENSING
Undersensing occurs when the pacemaker fails to detect spontaneous myocardial
depolarization, which results in asynchronous pacing

Atrial or ventricular pacing spikes arise regardless of P waves or QRS complex

This typically results in the appearance of too many pacing spikes, as seen on ECG

Causes :
• pacemaker programming problems (improper sensing threshold)
• insufficient myocardial voltage signal
• lead or pacer failure (fibrosis, fracture, etc.)
• an electrolyte abnormality.
UNDERSENSING
UNDERSENSING
Initial management
• Consider placement of a magnet to enable
asynchronous pacing
Treatment of the underlying cause
• Correct electrolyte abnormalities, treat
ischaemia, and remove non-essential
medications
Programming changes
• Increase the sensitivity
Device changes
• Lead revision and/or insertion (if a lead
problem)
OVERSENSING
• Oversensing occurs when the pacemaker senses electrical signals that it
should not normally encounter, which results in inappropriate inhibition of
the pacing stimulus
• In addition to the native cardiac depolarization signals (P or R waves), any
electrical signal with sufficient amplitude and frequent occurrence can be
sensed and can inhibit the pacemaker when pacing is needed

Causes :
• Physiologic signals like t waves
• By myopotential (and nonphysiologic) signals like electromagnetic
interference
• A lead failure (an insulation break or a lead fracture)
OVERSENSING
OVERSENSING
Initial management
• If the patient is not pacemaker dependent, then monitoring may be
appropriate pending elucidation of the underlying cause and provision of a
definitive treatment
• If the patient is pacemaker dependent, then IV isoproterenol may be
attempted prior to placement of a transvenous temporary pacemaker lead
Programming changes
• Lower the sensitivity
• Lengthening of the blanking or refractory period
Device changes
• Generator/battery change (if a generator/battery problem)
• Lead revision and/or insertion (if a lead problem)
PSEUDOMALFUNCTION

• Pseudomalfunctions are unusual and unexpected ECG findings that appear to be

pacemaker malfunctions but actually are normal pacemaker behavior

• Pseudomalfunctions are classified under 3 categories:

1) rate-related
2) atrioventricular (AV) interval/refractory period-related
3) model-related
PACEMAKER CROSSTALK
VENTRICULAR SAFETY PACING
• Ventricular safety pacing (SP) prevents ventricular asystole due to crosstalk

• Pacemaker crosstalk in a dual-chamber pacemaker refers to the detection of a

paced signal in one chamber by the lead in another chamber, and to the
misrepresentation of the paced signal as a cardiac depolarization signal

• This, results in inappropriate inhibition of pacing in the 2nd chamber.

• Ventricular safety pacing delivers a ventricular pacing stimulus after detecting a

ventricular “sense event” shortly after an atrial paced event

• Ventricular safety pacing typically results in the appearance of 2 very closely atrial
and ventricular paced events on ECG
PACEMAKER MEDIATED TACHYCARDIA (PMT)
• Pacemaker mediated tachycardia is an endless-loop tachycardia,
sustained, in part, by the presence of the pacemaker

• Pacemaker-mediated tachycardia requires the presence of retrograde

ventriculo-atrial conduction and a triggering event like premature
ventricular contraction or loss of AV synchrony

• Retrograde atrial activation is detected by the atrial sensor, which then

stimulates

• The rate of this tachycardia is limited by the pacemaker’s programmed

upper limit
PACEMAKER MEDIATED TACHYCARDIA
SPECIAL CONSIDERATIONS
MAGNET RESPONSE
• In most devices, placing magnet over a pacemaker temporarily turns
off the sensing, causing the device to pace in a asynchronous mode at
a fixed heart rate.
RADIOTHERAPY
• Inability to deliver radiotherapy (may result in mechanical
obstruction of the radiotherapy field)

• Oversensing (if radiotherapy average dose rate at the device exceeds

1cGy/min, the CIED may inappropriately sense direct or scattered
radiation as cardiac activity during the procedure)

• Device damage (exposing the device to high doses of direct or

scattered radiation with an accumulated dose greater than 100-500
cGy may damage the device)

• Device operational errors (exposing the device to scattered neutrons

may cause an electrical reset of the device, errors in device
functionality, errors in diagnostic data, or loss of diagnostic data)
Surgery
• Cautery use should be minimized, and the grounding pad should be kept distant from CIED site
• If a patient is pacemaker dependent the device can be programmed in an asynchronous mode
(e.g. DOO or VOO or using magnet) with the base rate increased to greater than intrinsic rate
• Monitor the heart rate with telemetry or pulse oximetry
Resuscitation
• ACLS protocols should be initiated if a patient enters a life-threatening cardiac arrhythmia
• Chest compressions should be continued regardless of the presence of CIED
External Cardioversion and Defibrillation
• Clinically appropriate energy output should be used regardless of the presence of a CIED
• The external pads or paddles should be positioned distant from the CIED pulse generator (10-15
cm away from the generator with an anterior-posterior vector)
• Patients who receive external shock must have their CIED interrogated afterwards to ensure that
device function and/or programming have not been altered
Central Line Placement
• Insertion of central venous lines and pulmonary artery catheters requires special care in CIED
patients
• Central lines: Subclavian venipuncture should be avoided ipsilateral to an implanted device. The
metal guidewire may contact the lead system during placement, such contact may generate
artifact.
• PA catheters: There is a risk lead dislodgement in passing PA catheters through the RA and RV.
PACEMAKER SYNDROME
• Intrinsic atrial impulses occur during or just after ventricular pacing in single chamber devices
• Impulses cause the atria to contract against closed AV valves
• This results in the reflux of blood back into the vena cavae and lungs
• Symptoms include
• Dyspnea, palpitations, nausea, chest pain/fullness, headache, lethargy, neck throbbing
• Management
• Upgrade to a dual-chamber (DDD) pacemaker and reprogram the AV delays

RUNAWAY PACEMAKER
• A runaway pacemaker is a rare medical emergency
• It is due to the total failure of a pacemaker generator, resulting in rapid tachycardia
• A magnet application is usually ineffective. Often the device must be manually disabled manual (disconnection of
the lead from the generator)

TWIDDLER SYNDROME
• It occurs due to unintentional or deliberate manipulation of the pacemaker pulse generator within its skin pocket by
the patient. This causes coiling of the lead and its dislodgement, resulting in failure of ventricular pacing.
• More commonly reported among elderly females with impaired cognition, the phenomenon usually occurs in the first
year following pacemaker implantation.
• Treatment involves repositioning of the dislodged leads and suture fixation of the lead and pulse generator within
its pocket.
TERIMA KASIH
MOHON BIMBINGAN
Troubleshooting PPM
Cause

 Failure to pace • Detecting • Pseudomalfunction

1. Output failure intracardiac 1. Crosstalk
2. Capture failure 1. Undersensing 2. Pacemaker mediated
2. Oversending tachycardia
3. Sensor induced tahcycardia
4. Runaway pacemaker
5. Lead displacement dysritmia
6. Twiddler syndrome
 Failure to pace
Output failure
Capture failure
 HR < programmed lower rate of pacemaker
 No pacing spike di EKG
• Generating pacing stimulus, no
 Cause :
myocard depolarization
1. Lead( fracture, displacement) • Pacing spike (+), QRS (-)
2. Generator failure
• Cause :
3. Battery failure
1. Lead dislodgement
4. Crosstalk inhibition
2. Low output
5. oversensing
3. Lead maturation
4. Lead/pacer failure (fibrosis,
fracture, low voltage, elevated
threshold)
Affect pacing threshold
• Threshold : minimum req energy to trigger depol of paced chamber
• Factor : antiaritmic drug, physical activity level, posture time of day,
 Detecting intracardiac
Undersensing
Oversensing
 Pacemaker fail to detect spontaneous
myocard depol • Pacemaker sense signal
 Asynchronous pacing. Too many pacing notnormal
 Cause : • Inappropriate inhibition of
1. Programming problem (improper threshold) stimulus
2. Insufficient myocard voltage sihnal
3. Lead/ pacer failure
• Cause
4. Electronic abnormality
1. T wave terbaca
2. Interference terbaca.
 Normal

Ventricular fusion & Pseudofusion

 V fusion : Electrical summation intrinsic beat & depol of pacing stimulus
 Adanya di antara full paced beat dgn complete intrinsic beat
 Pseudofusion : pacemaker pas on top of intrinsic beat.
Pseudomalfuction

 Unusual ECG appear in normal

pacemaker • Rate related : changed rate w/
Class
normal pacemaker function


1. Rate related (common)

2. AV interfal/ RP period
• Cause
3. Model related 1. Magnet operation
2. Timing variation (A-A/V-V)
3. Upper rate behavior
(weckenbach/ 2:1)
4. Pacemaker mediated tachy
(PMT)
5. Rate response
Pseudomalfuction

Ventricular safety pacing

 Prevent v asystole due to crosstalk
• Vent safety pacing memberi
 Crosstalk in dual chamber : detection v pacing stimulus setelah
of paced signal in 1 chamber by lead in membaca v sense event,
another chamber & misinterpret paced
signal as cardiac depol segera setelah a paced
 Jd inappropriate inhibisi in chamber event.
• Tampilannya 2 seri A paced
event yg dkt bgt dgn v
paced event
Pseudomalfuction

Pacemaker mediated tachycardia

 Endless loop tachycardia by presence
• Avoid dgn memanjangkan
of pacemaker Postventricular atrial
 Perlu ada konduksi VA retrograde dan refractory period (PVARP)
PVC atau AV dissinkroni
• Dihentikan dgn magnet
 Sama ky reentry tp pacemaker jd
circuit jg sehingga jd DOO, P R
dicuekin.
Pseudomalfuction

Upper rate behaviour

 Adalah karakter pada dual chamber
• Upper rate bergantung MTR
pacemaker jd atrial tracking mode & total atrila refractory
saat atrial rate naik hingga trashold
tertentu period (TARP)
 Dual chamber perlu setting • TARP : AV delay + PARP
ventriculare pace pada saat high atrial • Atrial > MTR : Wenckebach
rate : MTR maximum tracjking rate
• Bs lanjut jd 2:1 AV block
STEMI in VPR

 1) ST-segment elevation (STE) greater than or

equal to 1 mm for leads with a positive
(concordant) QRS complex;
 2) ST-segment depression (STD) greater than or
equal to 1 mm in leads V1, V2, or V3; and
 3) STE greater than or equal to 5 mm in leads
with negative (discordant) QRS complexes.