Pacemaker

Author(s)	J.S.S.G. de Jong
Moderator	J.S.S.G. de jong
Supervisor
some notes about authorship

A pacemaker is indicated when the electrical impulse conduction or formation is dangerously disturbed. The paced pacemaker rhythm can easily be recognized on the ECG as it shows pacemaker spikes: vertical signals that represent the electrical activity of the pacemaker. Usually these spikes are more visible in unipolar pacing than in bipolar pacing.

A (used) DDDr pacemaker

Chest x-ray of a patient with a pacemaker

Ventricular paced rhythm shows ventricular pacemaker spikes

DDD paced rhythm

Atrial sensed, ventricular paced rhythm (tracking). Note the LBBB morphology with left axis deviation indicating the pacing lead in the right ventricular apex.

Atrial paced rhythm

In the first example image, the atria are being paced, but not the ventricles, resulting in a atrial paced rhythm. Accordingly the ventricular beat is delayed until the atrial signal has passed the AV node. In the second image the ventricles are paced directly, resulting in ventricular paced rhythm. As ventricular pacing occurs exclusively in the right ventricle the ECG shows a left bundle branch pattern. An exception to this rule is left ventricular pacing in patients with congenital anomalies and patients with an epicardial pacemaker that has been placed during surgery. Another exception is septal or RVOT placement of the pacinglead which results in a less widened to normal QRS complex.

Pacemaker Coding

Pacemakers can be categorized according to the NASPE coding system, that usually consists of 3-5 letters.

The revised NASPE/BPEG generic code for antibradycardia pacing[1]

I	II	III	IV	V
Chamber(s) paced	Chamber(s) sensed	Response to sensing	Rate modulation	Multisite pacing
O = None	O = None	O = None	O = None	O = None
A = Atrium	A = Atrium	T = Triggered	R = Rate modulation	A = Atrium
V = Ventricle	V = Ventricle	I = Inhibited		V = Ventricle
D = Dual (A+V)	D = Dual (A+V)	D = Dual (T+I)		D = Dual (A+V)

Commonly Used Pacemakers

The most often used codes are:

• AAI: the atria are paced, when the intrinsic atrial rhythm falls below the pacemakers threshold
• VVI: the ventricles are paced, when the intrinsic ventricular rhythm falls below the pacemakers threshold
• VDD: the pacemaker senses the atrial en ventriculair events, but can only pace the ventricle. This type of pacemaker is used in patients with a reliable sinus node, but suffering from the results of an AV-block.
• DDD: the pacemaker records both the atrial and ventricular rate and can pace one of each chambers when needed.
• DDDR: as above, but the pacemaker has a sensor that records a demand for higher cardiac output and can adjust the heart rate accordingly.
• Biventricular pacemakers (CRT-P): leads in both ventricles are present to synchronize contraction. The lead pacing the left ventricle is usually positioned in the sinus coronarius. This cardiac synchronization therapy can improve symptoms and survival in some heart failure patients. Echo-optimizing might be helpful in finding the most effective pacingdelay between left and right ventricle.
• ICD (Internal Cardioversion Device): this device can detect and treat Ventricular Tachycardia and Ventricular Fibrillation. ICDs are a seperate category and usually not put in the pacemaker category, although they do have a pacing function. Usually the first treatment is anti-tachy pacing (pacing at a rate +- 10% above the ventricular rate in ventricular tachycardia, which can convert the rhythm to sinus rhythm). If this is not effective an defibrillator shock is delivered, usually with 16-36 Joules of energy. ICDs can save lives in patients who have a high risk of ventricular arrhythmias. All ICDs have optional pacemaker activity to treat bradycardias. New biventricular ICDs have 3 leads: an atrial lead, a left ventricular lead and a right ventricular lead.
• Biventricular ICDs (CRT-D): an ICD with biventricular pacing option.

Pacemaker Indications

A full list of pacemaker indications can be read in the ESC guidelines on cardiac pacing [2]. A selection of class I indications are: chronic symptomatic third- or second degree (Mobtiz I or II) atrioventricular block. Syncope with sinus node disease. Alternating bundle branch block. Persisting AV block after surgery.

Pacemaker Malfunction

to be filled in ...

Failure of appropriate capture, atrial

Failure of atrial capture in a patient with atrial standstill, no P waves are seen after the atrial stimuli

External Links

Heart Rhytm Society

References

1. Bernstein AD, Daubert JC, Fletcher RD, Hayes DL, Lüderitz B, Reynolds DW, Schoenfeld MH, and Sutton R. The revised NASPE/BPEG generic code for antibradycardia, adaptive-rate, and multisite pacing. North American Society of Pacing and Electrophysiology/British Pacing and Electrophysiology Group. Pacing Clin Electrophysiol. 2002 Feb;25(2):260-4. DOI:10.1046/j.1460-9592.2002.00260.x |
2. Vardas PE, Auricchio A, Blanc JJ, Daubert JC, Drexler H, Ector H, Gasparini M, Linde C, Morgado FB, Oto A, Sutton R, Trusz-Gluza M, European Society of Cardiology, and European Heart Rhythm Association. Guidelines for cardiac pacing and cardiac resynchronization therapy: The Task Force for Cardiac Pacing and Cardiac Resynchronization Therapy of the European Society of Cardiology. Developed in collaboration with the European Heart Rhythm Association. Eur Heart J. 2007 Sep;28(18):2256-95. DOI:10.1093/eurheartj/ehm305 |
3. Gregoratos G, Abrams J, Epstein AE, Freedman RA, Hayes DL, Hlatky MA, Kerber RE, Naccarelli GV, Schoenfeld MH, Silka MJ, Winters SL, Gibbons RJ, Antman EM, Alpert JS, Gregoratos G, Hiratzka LF, Faxon DP, Jacobs AK, Fuster V, Smith SC Jr, and American College of Cardiology/American Heart Association Task Force on Practice Guidelines/North American Society for Pacing and Electrophysiology Committee to Update the 1998 Pacemaker Guidelines. ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee to Update the 1998 Pacemaker Guidelines). Circulation. 2002 Oct 15;106(16):2145-61. DOI:10.1161/01.cir.0000035996.46455.09 |