temporary pacing
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Temporary PacingTemporary Pacing
William H. Sauer, MDWilliam H. Sauer, MD
Road MapRoad Map
IndicationsIndicationsMethods for PlacementMethods for PlacementBasic ProgrammingBasic Programming
Road MapRoad Map
IndicationsMethods for PlacementMethods for PlacementBasic ProgrammingBasic Programming
IndicationsIndications
Bradycardia in the Setting of MIBradycardia in the Setting of MIBradycardia not related to MIBradycardia not related to MIPrevention of VT/VFPrevention of VT/VFProphylaxisProphylaxis
Slow Heart Rates peri MISlow Heart Rates peri MI
Mobitz II after an anterior MIMobitz II after an anterior MINew fascicular block and long PRNew fascicular block and long PRAlternating Bundle Branch BlockAlternating Bundle Branch BlockMedically Refractory Sinus Node Medically Refractory Sinus Node
DysfunctionDysfunctionThird Degree AV blockThird Degree AV block
Bradycardia not related to MIBradycardia not related to MI
Medically Refractory Medically Refractory Symptomatic BradycardiaSymptomatic Bradycardia
Third degree AV block with wide Third degree AV block with wide QRS escapeQRS escape
Prevention of VT/VFPrevention of VT/VF
TdP relies on bradycardia dependence TdP relies on bradycardia dependence (long-short sequence)(long-short sequence)
Long QT3 – bradycardia dependentLong QT3 – bradycardia dependentMMVT requiring frequent ATPMMVT requiring frequent ATP
Prophylactic ImplantProphylactic Implant
Patients with LBBB requiring Swan-Ganz Patients with LBBB requiring Swan-Ganz catheter placementcatheter placement
Cardioversion in the setting of SSSCardioversion in the setting of SSSNew BBB in the setting of acute New BBB in the setting of acute
endocarditisendocarditisPeri-operativelyPeri-operatively
Road MapRoad Map
IndicationsIndicationsMethods for PlacementBasic ProgrammingBasic Programming
Types of Temporary PacersTypes of Temporary Pacers
TranscutaneousTranscutaneousTransesophogealTransesophogealEpicardialEpicardialTransvenousTransvenous
Types of Temporary PacersTypes of Temporary Pacers
TranscutaneousTranscutaneousTransesophogealTransesophogealEpicardialEpicardial
Transvenous
EquipmentEquipment
7F introducer and prep kit7F introducer and prep kitMobile C-Arm FluoroscopyMobile C-Arm FluoroscopyPacing LeadPacing LeadExternal PacemakerExternal PacemakerSuture and TegadermSuture and Tegaderm
AccessAccess
Leave the subclavian vein alone – an EP Leave the subclavian vein alone – an EP will need this space to implant the will need this space to implant the permanent pacer or ICDpermanent pacer or ICD
Right IJ is easiest access to the right Right IJ is easiest access to the right ventricleventricle
Femoral Vein is next easiest to move a Femoral Vein is next easiest to move a non-deflectable catheter to the RVnon-deflectable catheter to the RV
Left IJ is last resortLeft IJ is last resort
The pacing leadThe pacing lead
The lead is a spear that will pierce the The lead is a spear that will pierce the heart – be gentleheart – be gentle
Balloon-tipped catheters are preferableBalloon-tipped catheters are preferableThe pacing port on the SGC is lethalThe pacing port on the SGC is lethalLeave a little bit of slack – but do not make Leave a little bit of slack – but do not make
the lead buckle in the heartthe lead buckle in the heart
Road MapRoad Map
IndicationsIndicationsMethods for PlacementMethods for PlacementBasic Programming
NBG Code ReviewNBG Code Review
IChamber
Paced
IIChamber
Sensed
IIIResponseto Sensing
IVProgrammableFunctions/Rate
Modulation
VAntitachy
Function(s)
V: Ventricle V: Ventricle T: Triggered P: Simpleprogrammable
P: Pace
A: Atrium A: Atrium I: Inhibited M: Multi-programmable
S: Shock
D: Dual (A+V) D: Dual (A+V) D: Dual (T+I) C: Communicating D: Dual (P+S)
O: None O: None O: None R: Rate modulating O: None
S: Single (A or V)
S: Single (A or V)
O: None
Single Chamber Timing Single Chamber Timing TerminologyTerminology
Lower rateLower rateRefractory periodRefractory periodBlanking periodBlanking periodUpper rateUpper rate
Lower Rate IntervalLower Rate Interval
Lower Rate Interval
VP VP VVI / 60
Defines the lowest rate the pacemaker will paceDefines the lowest rate the pacemaker will pace
Refractory PeriodRefractory Period
Lower Rate Interval
VP VP VVI / 60
Interval initiated by a paced or sensed Interval initiated by a paced or sensed eventevent
Designed to prevent inhibition by Designed to prevent inhibition by cardiac or non-cardiac eventscardiac or non-cardiac events
Refractory Period
Blanking PeriodBlanking Period
Lower Rate Interval
VP VP VVI / 60
The first portion of the refractory periodThe first portion of the refractory period Pacemaker is “blind” to any activityPacemaker is “blind” to any activity Designed to prevent oversensing pacing stimulusDesigned to prevent oversensing pacing stimulus
Blanking PeriodRefractory Period
VOO ModeVOO Mode
Blanking Period
VP VP
Lower Rate Interval
VOO / 60
Asynchronous pacing delivers output Asynchronous pacing delivers output regardless of intrinsic activityregardless of intrinsic activity
Rate = 60 bpm / 1000 msA-A = 1000 ms
APVP
APVP
V-AAV V-AAV
Atrial Pace, Ventricular Pace (AP/VP)Atrial Pace, Ventricular Pace (AP/VP)
Four “Faces” of Dual Chamber Four “Faces” of Dual Chamber PacingPacing
Rate = 60 ppm / 1000 msA-A = 1000 ms
AP VS
AP VS
V-AAV V-AAV
Atrial Pace, Ventricular Sense (AP/VS)Atrial Pace, Ventricular Sense (AP/VS)
Four “Faces” of Dual Chamber Four “Faces” of Dual Chamber PacingPacing
ASVP
ASVP
Rate (sinus driven) = 70 bpm / 857 msA-A = 857 ms
Atrial Sense, Ventricular Pace (AS/ VP)Atrial Sense, Ventricular Pace (AS/ VP)
V-AAV AV V-A
Four “Faces” of Dual Chamber Four “Faces” of Dual Chamber PacingPacing
Rate (sinus driven) = 70 bpm / 857 msSpontaneous conduction at 150 msA-A = 857 ms
ASVS
ASVS
V-AAV AV V-A
Atrial Sense, Ventricular Sense (AS/VS)Atrial Sense, Ventricular Sense (AS/VS)
Four “Faces” of Dual Chamber Four “Faces” of Dual Chamber PacingPacing
Dual Chamber Timing Dual Chamber Timing ParametersParameters
Lower rateLower rateAV and VA intervalsAV and VA intervalsUpper rate intervalsUpper rate intervalsRefractory periodsRefractory periodsBlanking periodsBlanking periods
Lower Rate Interval
APVP
APVP
Lower Rate Lower Rate
The lowest rate the pacemaker will pace the The lowest rate the pacemaker will pace the atrium in the absence of intrinsic atrial eventsatrium in the absence of intrinsic atrial events
DDD 60 / 120
APVP
ASVP
PAV SAV
200 ms 170 ms
Lower Rate Interval
AV IntervalsAV Intervals
Initiated by a paced or non-refractory sensed atrial Initiated by a paced or non-refractory sensed atrial eventevent Separately programmable AV intervals – SAV /PAVSeparately programmable AV intervals – SAV /PAV
DDD 60 / 120
APVP
ASVP
PAV SAV
200 ms 170 ms
Lower Rate Interval
AV IntervalsAV Intervals
Initiated by a paced or non-refractory sensed atrial Initiated by a paced or non-refractory sensed atrial eventevent Separately programmable AV intervals – SAV /PAVSeparately programmable AV intervals – SAV /PAV
DDD 60 / 120
Atrial Escape Interval (V-A Interval)Atrial Escape Interval (V-A Interval)
Lower rate interval– AV intervalV-A interval
Lower Rate Interval
APVP
APVP
AV Interval VA Interval
Atrial Escape Interval (V-A Interval)Atrial Escape Interval (V-A Interval)
The interval initiated by a paced or sensed The interval initiated by a paced or sensed ventricular event to the next atrial eventventricular event to the next atrial event
DDD 60 / 120PAV 200 ms; V-A 800 ms
200 ms 800 ms
Post Ventricular Atrial Refractory Period (PVARP)
Refractory PeriodsRefractory Periods
VRP and PVARP are initiated by sensed or VRP and PVARP are initiated by sensed or paced ventricular eventspaced ventricular events The VRP is intended to prevent self-inhibition such The VRP is intended to prevent self-inhibition such
as sensing of T-waves as sensing of T-waves The PVARP is intended primarily to prevent The PVARP is intended primarily to prevent
sensing of retrograde P wavessensing of retrograde P waves
AP
VPVentricular Refractory Period (VRP)
A-V Interval(Atrial Refractory)
Blanking PeriodsBlanking Periods
First portion of the refractory period-sensing is First portion of the refractory period-sensing is disableddisabled
AP
VP
AP
Post Ventricular Atrial Blanking (PVAB)
Post Atrial Ventricular Blanking
Ventricular Blanking (Nonprogrammable)
Atrial Blanking (Nonprogrammable)
Upper Rate Behaviors –Upper Rate Behaviors –Wenckebach and 2:1 BlockWenckebach and 2:1 Block
Lower rate
Atrial rate
Ven
tric
ula
r ra
te
Upper rate
Atrialtracking
PVARP
Upper Tracking Rate
Lower Rate Interval
{P Waves Blocked
AS AS
VPVP
SAV = 200 msPVARP = 300 ms
Thus TARP = 500 ms (120 ppm)
DDDLR = 60 ppm (1000 ms)
UTR = 100 bpm (600 ms)Sinus rate = 66 bpm (900 ms)
SAV
TARP
PVARP
Total Atrial Refractory Period Total Atrial Refractory Period (TARP)(TARP)
Sum of the AV Interval and PVARPSum of the AV Interval and PVARP
SAV
PVARP
Wenckebach OperationWenckebach Operation
Upper Tracking Rate
Lower Rate Interval {
AS AS AR APVPVP VP
TARPSAV PAV PVARP SAV PVARP
P Wave Blocked (unsensed or unused)
DDD Sinus rate = 109 bpm (550 ms) LR = 60 bpm (1000 ms) UTR = 100 ppm (600 ms)
SAV = 200 ms PAV = 230 ms PVARP = 300 ms
Prolongs the SAV until upper rate limit Prolongs the SAV until upper rate limit expiresexpires Produces gradual change in tracking rate ratioProduces gradual change in tracking rate ratio
TARP TARP
Wenckebach OperationWenckebach Operation
DDD / 60 / 120 / 310
Every other P wave falls into refractory and Every other P wave falls into refractory and does not restart the timing intervaldoes not restart the timing interval
Upper Tracking Limit
Lower Rate Interval {
{P Wave Blocked
AS AS
VPVPARAR
Sinus rate = 150 bpm (450 ms)PVARP = 300 ms SAV = 200 msTracked rate = 66 bpm (900 ms)
AV PVARP AV PVARP
TARP TARP
2:1 Block2:1 Block
2:1 Block2:1 Block
DDD / 60 / 120 / 310
CasesCases
Syncope - Indication for Syncope - Indication for Temporary Pacer?Temporary Pacer?
Asymptomatic - Indication for Asymptomatic - Indication for Temporary Pacer?Temporary Pacer?
Asymptomatic - Indication for Asymptomatic - Indication for Temporary Pacer?Temporary Pacer?
Asymptomatic when lying downAsymptomatic when lying down
Is This Normal Device Is This Normal Device Operation?Operation?
Is This Normal Device Operation? What Is This Normal Device Operation? What Feature Might You Want to Have Feature Might You Want to Have
Programmed On?Programmed On?
Is This Normal Device Is This Normal Device Operation? Operation?
Is This Normal Device Is This Normal Device Operation?Operation?