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CARDIOVASCULAR TEAM

SYMPOSIUM 2017:Applying a Cardiovascular Team Approach to Daily Practice

Saturday, November 4th, 2017

Francisco Aguilar MD, FACC, FHRS

Cardiac Clinical Electrophysiology

AMITA Health Medical Group Heart and Vascular

CARDIOVASCULAR

TEAM SYMPOSIUM 2017

Everything You Wanted To Know About

Cardiac Pacing But Were Afraid To Ask

Disclosures

• Principal Investigator for the GLORIA-AF

registry funded by Boerhringer Ingelheim.

• Sub-Principal Investigator MINT Study.

• Sub-Principal Investigator MPP Trial.

• History of Cardiac Pacing

• Mechanics of Modern Pacing

• Clinical Pearls / Cases / Questions

• Directions for the Future

Everything You Wanted To Know About

Cardiac Pacing But Were Afraid To Ask

• History of Cardiac Pacing

• Mechanics of Modern Pacing

• Clinical Pearls / Cases / Questions

• Directions for the Future

Everything You Wanted To Know About

Cardiac Pacing But Were Afraid To Ask

History of Cardiac Pacing

• 1st Clinical Electrical Cardiac Activation - 1928

– Mark C. Lidwell (Australian anesthesiologist)

– Used alternating electrical current and a needle to

start the heart of a newborn.

• First “Artificial Pacemaker” - 1932

– Albert Hyman (American physiologist)

– Used needles with epinephrine injected into the

heart to treat cardiac standstill.

– The action potential created by the needle that stuck

the heart.

Mittal. Ind J Thorac Cardiovasc Surg, 2005; 21: 236-249

Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.

First Hyman Device

Hyamn’s Device in a Box

Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.

First Artificial Pacemaker

• Hand-crank drove a DC current generator.

• The electrical impulses were directed into the

patient's right atrium through a bipolar needle

electrode introduced via an intercostal space.

• Pacing could be delivered at rates of 30, 60 or

120 per minute.

• Intended to start stillborn hearts.

• Not intended to treat symptomatic bradycardia.

Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.

“THE HYMENOTOR”

Popular Science. Self-Starter for Dead Man’s Heart (Oct, 1933)

History of Cardiac PacingSurgery Drives the Field

• 1949 - Wilfred Bigelow and John Callaghan of Canada

used hypothermia to induce asystole in order to perform

cardiac surgery.

– Problem: In the re-warming phase the heart would

not often restart.

– Eureka moment: Surgery on a dog. Heart restarted

by poking the heart with a probe.

– Result: Experimentation with sino-atrial pacing.

Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.

History of Cardiac Pacing

The Grass Stimulator• In the 1940s and 1950s

the principle device

available to generate a

variety of electrical

impulses for physical

stimulation was the

Grass Stimulator.

Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.

History of Cardiac Pacing

The HoppsPacemaker• John Hopps, an electrical

engineer, worked with the

National Research Council

of Canada.

• Designed first electronic

device acting as pacemaker.

• External unit driven by

vacuum tubes.

• Electrical impulses were

transmitted via a bipolar

catheter electrode to the

atria using a transvenous

approach.

Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.

History of Cardiac Pacing

External Pacing

• Paul M. Zoll in 1950 developed the first external

pacemaker building on Bigelow and Hopp’s work.

Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.

1952 – The Electrodyne PM-65.

Earl Bakken

• Electrical Engineer

• Co-Founder Medtronic

• TV Repairman

History of Cardiac Pacing1957 -The First Battery Operated Pacemaker

www.earlbakken.com

http://mcad-mural.blogspot.com/

“So small and light that it may be attached to and worn by

the patient…”

Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.

History of Cardiac Pacing1958 -The First Self Contained Implanted Pacemaker

Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.Arne Larsson

History of Cardiac Pacing

Arne Larsson• Hospitalized with CHB / frequent Stokes-Adams attacks for 6

months.

• He was having 20 to 30 attacks daily and his prognosis was poor.

• Else Marie Larsson pleaded with Ake Senning and Rune Elmqvist

Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.

The Surgeon The Engineer

Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.

Senning wrote:

“On the 8th October 1958, in the

evening, when there were no

extra people in the theatre, I

implanted the first pacemaker,

but it lasted only 8 hours.”

The second pacemaker

functioned well for about 1 week,

but suddenly failed from a lead

fracture.

History of Cardiac Pacing

Arne Larsson• Arne Larsson required:

– Five lead systems.

– 22 pulse generators of 11 different models.

• Died December 28th, 2001 at age 86 from Malignancy

• He outlived the surgeon and engineer who saved his life.

Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.

Pacers of the 60s

Pacers of the 70s

Nuclear Pacemakers

• Designed by multiple manufactures in the early

1970s.

Prutchi, D. Nuclear Pacemakers.

Pu - 238

Pacers of the 80s

Pacemakers of Today

• History of Cardiac Pacing

• Mechanics of Modern Pacing

• Clinical Pearls / Cases / Questions

• Directions for the Future

Everything You Wanted To Know About

Cardiac Pacing But Were Afraid To Ask

Mechanics of Modern Pacing

• Leads

• Device Systems

– Single Chamber

– Dual Chamber

– Biventricular

Leads

Kenny T. The Nuts and Bolts of Cardiac Pacing. Wiley-Blackwell. 2008.

Haynes et al. Cardiac Pacing, Defibrillation and Resynchronization. Wiley-Blackwell, 2013.

Fixation

Fixation

How do pacing leads sense and pace?

Device Systems

Single Chamber

Children’s Hospital of Wisconsin Website.

Device Systems

Dual Chamber

Children’s Hospital of Wisconsin Website.

Device Systems

Biventricular

Device Systems

Biventricular

www.nature.com

Device Systems

Biventricular

• Cardiac Resyncronization Therapy

– Block-HF:

• NYHA Class I, II, III / LVEF 30-50%, AV block

• CRT superior to RV pacing for: death, HF, ventricular

remodeling.

– MADIT-CRT

• NYHA Class I, II / LVEF <35%, LBBB

• CRT resulted in reduced HF hospitalizations, improved EF

• Two year analysis showed a mortality benefit over

conventional therapy.

• History of Cardiac Pacing

• Mechanics of Modern Pacing

• Clinical Pearls / Scenarios / Questions

• Directions for the Future

Everything You Wanted To Know About

Cardiac Pacing But Were Afraid To Ask

How does a pacer regulate heart

rate?

• Accelerometer.

– Piezoelectric crystal senses motion.

• Tissue contact crystal.

– Minute ventilation senses respiration characteristics.

What do magnets do to pacemakers?

• Magnets make the pacemaker pace

ASYNCHRONOUSLY at a set rate per the

manufacturer. Sensing is disabled.

What do magnets do to pacemakers?

What do magnets do to pacemakers?

Why use a magnet on a pacemaker?

• Check if a pacemaker has ample battery, needs

to be replaced or completely dead.

• When you want to make sure the pacemaker will

pace SURGERY.

What do magnets do to ICDs?

• Disable tachy-therapies.

– There will be no treatment for VT or VF.

– Pacing is NOT impacted.

– Permanent programming is not impacted.

Does any device need to be checked

before and after surgery?

• No.

• They should be checked in the office routinely

independent of surgery.

– Every three months.

• There should be instructions from the

cardiology office with respect to what do with

the device during surgery cautery.

• Programming changes cannot be made with a

magnet.

Noise

Kenny T. Paced ECG Interpretation. Wiley-Blackwell. 2009.

Does a pacemaker always have to

pace?

• No.

• Pacemakers regulate the heart rate by stimulating

the heart when it is too slow.

• Pacemakers can do very little for fast heart rates.

• Pacemakers have hysteresis settings what you

see is not always what you get.

• Many times we DO NOT want the patient to

pace.

• History of Cardiac Pacing

• Mechanics of Modern Pacing

• Clinical Pearls / Cases / Questions

• Directions for the Future

Everything You Wanted To Know About

Cardiac Pacing But Were Afraid To Ask

Directions for the Future

• Leadless Pacing

• HIS Bundle Pacing

Leadless Pacing

Leadless Pacing

• MICRA Pacing Study – 725 patients. 719

implants (99.2%)

– Freedom from device complications at one year 96%.

• Pacer Characteristics:

– Single chamber pacing.

– 10 year battery life.

– Rate responsiveness.

– Implant with a 23 F sheath.

St. Jude Nanostim

HIS Bundle Pacing

• Pacing methodology where there is from a

location higher on the conduction system to

take advantage of existing cardiac structures and

electrical pathways.

HIS Bundle Pacing

HIS Bundle Pacing

Minnesota Star Tribune.

HIS Bundle Pacing

HIS Bundle Pacing

Thank You !!!

References

• Mittal T. Pacemakers – A journey through the years. Indian J Thorac

Cardiovascular Surg, 2005; 21: 236-249.

• Popular Science. Self-Starter for Dead Man’s Heart (Oct, 1933)

• Aquilina O. A brief history of cardiac pacing. Images in Paediatric Cardiology.

2006;8(2):17-81.

• Furman S. Early History of Cardiac Pacing and Defibrillation. Indian Pacing

and Electrophysiology Journal, 2(1): 2-3 (2002).

• Prutchi, D. Nuclear Pacemakers.

• Kenny T. The Nuts and Bolts of Cardiac Pacing. Wiley-Blackwell. 2008.

• Kenny T. Paced ECG Interpretation. Wiley-Blackwell. 2009.

• Haynes et al. Cardiac Pacing, Defibrillation and Resynchronization. Wiley-

Blackwell, 2013.