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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
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CARDIOVASCULAR
TEAM SYMPOSIUM 2017
Everything You Wanted To Know About
Cardiac Pacing But Were Afraid To Ask
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Disclosures
• Principal Investigator for the GLORIA-AF
registry funded by Boerhringer Ingelheim.
• Sub-Principal Investigator MINT Study.
• Sub-Principal Investigator MPP Trial.
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• 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
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• 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
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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
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Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.
First Hyman Device
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Hyamn’s Device in a Box
Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.
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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.
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“THE HYMENOTOR”
Popular Science. Self-Starter for Dead Man’s Heart (Oct, 1933)
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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.
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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.
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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.
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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.
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1952 – The Electrodyne PM-65.
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Earl Bakken
• Electrical Engineer
• Co-Founder Medtronic
• TV Repairman
History of Cardiac Pacing1957 -The First Battery Operated Pacemaker
www.earlbakken.com
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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.
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History of Cardiac Pacing1958 -The First Self Contained Implanted Pacemaker
Aquilina O. Images in Pediatric Cardiology. 2006;8(2):17-81.Arne Larsson
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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
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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.
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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.
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Pacers of the 60s
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Pacers of the 70s
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Nuclear Pacemakers
• Designed by multiple manufactures in the early
1970s.
Prutchi, D. Nuclear Pacemakers.
Pu - 238
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Pacers of the 80s
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Pacemakers of Today
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• 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
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Mechanics of Modern Pacing
• Leads
• Device Systems
– Single Chamber
– Dual Chamber
– Biventricular
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Leads
Kenny T. The Nuts and Bolts of Cardiac Pacing. Wiley-Blackwell. 2008.
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Haynes et al. Cardiac Pacing, Defibrillation and Resynchronization. Wiley-Blackwell, 2013.
Fixation
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Fixation
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How do pacing leads sense and pace?
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Device Systems
Single Chamber
Children’s Hospital of Wisconsin Website.
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Device Systems
Dual Chamber
Children’s Hospital of Wisconsin Website.
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Device Systems
Biventricular
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Device Systems
Biventricular
www.nature.com
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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.
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• 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
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How does a pacer regulate heart
rate?
• Accelerometer.
– Piezoelectric crystal senses motion.
• Tissue contact crystal.
– Minute ventilation senses respiration characteristics.
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What do magnets do to pacemakers?
• Magnets make the pacemaker pace
ASYNCHRONOUSLY at a set rate per the
manufacturer. Sensing is disabled.
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What do magnets do to pacemakers?
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What do magnets do to pacemakers?
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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.
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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.
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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.
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Noise
Kenny T. Paced ECG Interpretation. Wiley-Blackwell. 2009.
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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.
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• 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
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Directions for the Future
• Leadless Pacing
• HIS Bundle Pacing
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Leadless Pacing
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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.
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St. Jude Nanostim
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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.
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HIS Bundle Pacing
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HIS Bundle Pacing
Minnesota Star Tribune.
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HIS Bundle Pacing
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HIS Bundle Pacing
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Thank You !!!
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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.