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Dual Chamber Temporary Pacing Operations

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Temporary Pacing Operations & Troubleshooting Indications for Dual Chamber Temporary Pacing Complete heart block Sinus bradycardia Bradycardia with congestive heart ... – PowerPoint PPT presentation

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Title: Dual Chamber Temporary Pacing Operations


1
Dual Chamber Temporary PacingOperations
Troubleshooting
2
Indications for Dual Chamber Temporary Pacing
  • Complete heart block
  • Sinus bradycardia
  • Bradycardia with congestive heart failure
  • Atrial and/or ventricular ectopic arrhythmia
  • Reentrant tachycardias
  • During pulse generator replacement

3
Indications for Dual Chamber Temporary Pacing
  • Prior to the implant of a permanent pacemaker
  • Temporary support of a patient after heart
    surgery
  • Acute myocardial infarction complicated by heart
    block
  • High rate burst stimuli for the treatment of
    some tachyarrhythmias

4
The NASPE/BPEG Generic (NBG) Code
Position
I
II
III
IV
V
Category
Chamber(s)Paced
Chamber(s)Sensed
Response toSensing
ProgrammabilityRate Modulation
AntitachyarrhythmiaFunction(s)
O None A Atrium V Ventricle D Dual (AV)
O None A Atrium V Ventricle D Dual (AV)
O None T Triggered I Inhibited D Dual
(TI)
O None P Simple Programmable M
Multiprogrammable C Communicating R Rate
Modulation
O None P Pacing S Shock D Dual (PS)
ManufacturersDesignationOnly
S Single (A or V)
S Single (A or V)
Note Positions I through III are used
exclusively for antibradyarrhythmia function
5
Asynchronous Modes
AOO
VOO
DOO
6
DVI
1
2
3
4
5
6
AV interval (140 ms)
Lower rate 60 ppm V-A interval 860 ms
PVARP (250 ms)
indicates cycle restarted by sensed or paced
event
7
DDD Pacing
Chamber Paced
Chamber Sensed
Action or Responseto a Sensed Event
D
D
D
8
DDD Pacemaker
  • Provides
  • AV Synchrony
  • Rate Variability
  • Results in
  • Changes in cardiac output
  • Management of rhythm
  • Improved quality of life

9
Parameter Adjustments of theTemporary DDD
Pacemaker
  • Lower Rate
  • AV Interval
  • Upper Rate
  • Output
  • Sensitivity
  • Refractory Period(PVARP)

10
ECG Function DDD Mode
11
Timing Intervals in milliseconds (ms)
VA 750 ms
AV 250 ms
VV 1000 ms
DDD / 60 / 250 / 125 / 155
12
Calculation of Atrial Escape Interval
  • Atrial Escape Lower Rate AV
    Interval Interval
  • VV AV VA (ms) (ms) (ms)
  • (60 ppm) 1000 250 750
  • (60 ppm) 1000 150 850
  • (70 ppm) 850 200 650

13
Proper Atrial Sensingis the Heart
ofPhysiologic Pacing
14
A Pace / V Pace
AV Sequential Pacing
VA 750 ms
AV 250 ms
VV 1000 ms
DDD / 60 / 250 / 150
15
A Pace / V Sense
Atrial Pacing with Normal AV Conduction
Programmed Lower Rate1000 msActual VV960 ms
DDD / 60 / 200 / 150
16
A Sense / V Pace
Atrial Synchronous Pacing
Spontaneous Atrial Rate 55 ppm
Spontaneous Atrial Rate 110 ppm
DDD / 50 / 150 / 150
17
A Sense / V Sense
Spontaneous P-Wave with Normal AV Conduction
Spontaneous Atrial Rate 65 ppm Spontaneous P-R
Interval 160 ms
DDD / 60 / 200 / 150
18
Timing Operations of DDD Pacing
VentricularRate
UpperRate
AtrialTracking
LowerRate
Atrial Rate
19
Definitions
  • PVARP Post Ventricular Atrial Refractory Period
  • Time after Vs or Vp when atrial rates are
    ignored
  • AV Time from As or Ap to Vp in ms
  • TARP Total Atrial Refractory Period in ms

20
Refractory Period
  • Increase to prevent
  • T-wave sensing
  • P-wave sensing
  • Decrease to permit tachy pacing

21
Wenckebach Operation
22
Wenckebach Operation
AV
AV
W
AV
W
AV
W
AV
PVARP
PVARP
PVARP
PVARP
PVARP
Upper Rate
Upper Rate
Upper Rate
Upper Rate
Upper Rate
As
As
As
As
As
As
Vp
Vp
Vp
Vp
Vp
W Wenckebach Interval
23
2 1 Block
24
2 1 Block
AV
AV
AV
AV
PVARP
PVARP
PVARP
PVARP
Upper Rate
Upper Rate
Upper Rate
Upper Rate
As
As
As
As
As
As
As
As
Vp
Vp
Vp
Vp
25
Physiology of Retrograde Conduction
1. Loss of A-V synchrony due to a PVC
2. Sensed retrograde activation
3. A-V interval initiated
PVC
4. Prolongation of A-V interval
5. Ventricular pacing synchrononized to
retrograde P-waves
26
Pacemaker Mediated Tachycardia (PMT)
  • Fast ventricular paced rhythm
  • Synchronized to retrograde-conducted P-waves
  • Not normal sinus tachycardia

27
Thresholds
28
Feature of the Temporary DDD Pacemaker
  • Output Control

Atrial
Ventricular
Pulse Amplitude(ma)
Pulse Width(ms)
29
Feature of the Temporary DDD Pacemaker
Sensitivity
2.5
1.25
0.5
30
Troubleshooting
31
Undersensing
  • Failure of the pacemaker to senseintrinsic
    R-waves or intrinsic P-waves

32
Undersensing
  • Battery depletion
  • Decreased QRS voltage
  • Fusion beat
  • Dislodged/fractured lead
  • Inappropriate sensitivity setting

33
Oversensing
  • Inhibition of the pacemaker by events the
    pacemaker should ignore, e.g. EMI, T-waves, and
    myopotential

34
Oversensing
  • Myopotential inhibition
  • EMI
  • T-waves outside of refractory period
  • Dislodged/fractured lead
  • Inappropriate sensitivity setting

35
No Output
  • Pacemaker fails to emit stimuliat the programmed
    intervals

36
No Output
1
2
3
4
5
AP
AS
AP
AP
AP
VP
VP
VP
VP
VP
No atrial output (on ECG)
  • Battery depletion/pacemaker off
  • Oversensing
  • Faulty cable connection
  • Dislodged/fractured lead

37
Loss of Capture
  • Electrical stimuli delivered bythe pacemaker
    does not initiate depolarization of the atria or
    ventricle

38
Loss of Capture
Atrial
Noncapture
Ventricular
Noncapture
Fusion
  • Inappropriate output setting
  • Increased resistance to conduction
  • QRS complex not visible
  • Dislodged/fractured lead
  • Tissue is refractory
  • Faulty cable connection

39
Ventricular Safety Pacing
Ap
Vp
Ap Atrial Pace Vp Ventricular Pace
ProgrammedA-V Interval
Ventricular Blankingat Atrial Rate
12 ms
Ventricular SafetyPace Interval
110 ms
Programmed A-V Interval
Ventricular Sensing within this period triggers a
ventricular output at an A-V interval of 110 ms
instead of programmed A-V interval.
Ventricular Sensing during the remainder of the
programmed A-V interval inhibits the ventricular
output. If there is no sensed event, a
ventricular output occurs at the programmed A-V
interval.
40
Ventricular Safety Pacing (VSP)
1
2
3
4
5
AV interval (160 ms)
Lower rate 54 ppm Upper rate 180 ppm V-A
interval 860 ms
PVARP (250 ms)
indicates cycle restarted by sensed or paced
event
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