Pacemaker follow up and Pacemaker follow up and troubleshootingtroubleshooting

When the patient leaves the cath. lab with a permanent pacemaker

what should I do?

Should I?

A- Educate the patient .

B- Document.

C- Start follow up.

D- Non of the above.

E- All of the above.

Educate The patient

Wound care activity

Concerns Follow up

•The pacemaker site should be kept clean and dry. •The patient may take a tub bath when you go home after getting a pacemaker, but keep the incision dry for at least two weeks.•The dressing should be changed every day using sterile gauze. •He must not use ointment on the incision site unless instructed to do so by the doctor. •Carefully inspect the incision with each dressing

change to note any redness, swelling or discharge.

•The arm on the same side as the pacemaker should not be lifted above shoulder level for four weeks. •He should be careful not to hit or rub the insertion site. •Instruct the patient not to "fiddle" or play with the pacemaker under your skin. •avoid activities like heavy lifting, running, or contact sports. Do not lift more than 5 kilograms for two weeks. If you have any specific questions regarding activity, ask your doctor. •It is best to take it easy for four weeks at home to avoid damaging the pacemaker.

•Cellular Phones: You may use a cellular phone; however, do not hold the cellular phone on the same side as your pacemaker or place it in your shirt pocket over the pacemaker.• Strong Magnets: Avoid strong magnets. Examples are magnets used for an MRI and hand-held security wands.•Strong Electrical Fields: Avoid strong electrical fields. Examples are radio transmitting towers, ham radios, and arc welders. Also, avoid leaning over the open hood of a running car because its electrical field can interfere with your pacemaker. •Microwave Ovens: You may cook with a microwave oven. Microwave ovens in good working order are safe to use.

•Emphasize on the importance of follow up

•Give him the exact place and time

•Provide him with a phone number

Document

• Demographic information on patient

•Pacemaker operative record

•Manufacturer, model number and serial number of all implanted hardware

•Records of data from each follow-up visit

• Patient symptoms or complaints

•Evaluation of the pacemaker site

•Documentation of hardware advisory or recall, or any surgical complications

•Current medications

What is the aim of the follow up visits?

1- patient and family education.

2- Collect and maintain patient records and institutional databases.

3- Optimize pacing system function including maximizing power source utilization.

4- detect and correct pacemaker system abnormalities.

5- Act as a resource centre for cardiac pacing (RESERCH AND TRAINING)

Frequency Of Pacemaker Follow Up

PostimplantationPostimplantation Two weeksTwo weeks

12 weeks12 weeks

Maintenance period Maintenance period

Six monthsSix months

Intensified follow up Intensified follow up period period

Considerations in determining a pacemaker follow-up schedule

Patient-related Patient-related considerationsconsiderations

Pacer system-related Pacer system-related considerations considerations

• Patient dependency on pacing.

• Stability of rhythm and cardiovascular symptoms.

• High or unstable thresholds or low and stable thresholds.

• Patient’s ability to report symptoms accurately.

• Patient distance from follow-up clinic.

• Known reliability of the implanted pacing system.• How long the patient has had the pacemaker • Programmed parameters (higher outputs =

shorter time from elective replacement time to end of service)

• Complexity of pacing system. • Collection duration for diagnostics. • Concurrent use of implantable cardioverter-

defibrillator. • Application of cardioversion, electrocautery or

defibrillation.

Troubleshooting

Patient related Patient related problems problems

What troubles to shoot?

1- pocket related problems.

2- pacemaker syndrome.

3- accessory muscle stimulation.

Under passing or no Under passing or no pacingpacing

Patient related Patient related problems problems

What troubles to shoot?

Battery depletion

Generator failure:

1- temporary.

2- perminant.

Over sensing:

1-myopotential.

2- interference.

3-cross-talke.

4- fare field sensing.

Improper fixation.

Lead problems:

1- twiddelers syndrome.

2- lead fructure.

3- insulation breake

Electrode tissue interface:

1- lead imaturity.

2- electrolytes.

3- drugs.

4- MI.

Current is escaping

Decreased Resistance

Increased Current Drain

Pacing and sensing problems

Current cannot reach heart

Increased Resistance

Decreased Current Drain

Pacing and sensing problems

The ability of a device to sense intrinsic signals

Think of sensitivity as a wall. Raise the wall and you cansee less. Lower the wall andyou see more.

1.0 mV

4.0 mV

2.0 mV

MyopotentialOversensing

T - WaveOversensing

Pacing system senses signals other thanP/R waves and inhibits pacing output.

1.0 mV

4.0 mV

2.0 mV

Under passing or no Under passing or no pacingpacing

Over passing Over passing

Patient related Patient related problems problems

What troubles to shoot?

Interference: MRI.

Under sensing:

1-Lead problem

2- Electrode tissue interface.

1- Endless loop tachycardia.

2- Atrial arrhythmia or myopotential

To correct:Programming a lower number increases the sensitivity of the device, causing more signals to be sensed.

1.0 mV

4.0 mV

2.0 mV

Under passing or no Under passing or no pacingpacing

Over passing Over passing

Patient related Patient related problems problems

What troubles to shoot?

Psudo-malfunction Psudo-malfunction

1- hysteresis.,

2- rate smoothing.

3- mood swithc.

4- fusion and psudo-fusion.

Escape Interval = Pacing interval

45

50

55

60

65

70

A

B C

Hysteresis Rate

LRL

Rate (ppm)

A - Pacing inhibited by intrinsic rate > LRLB - Intrinsic rate falls below the Hysteresis Offset, pacing rate jumps to LRLC - DDD pacing at the LRL

B

Rate Hysteresis with Rate Smoothing

Fusion Beats: CHANGE in MORPHOLOGY

An intrinsic cardiac depolarization occurssimultaneously with the pacemaker output pulse.

Fusion Fusion

The pacemaker paces immediately after, or in anintrinsic depolarization.

Pseudofusion