Transcript Pacemaker Follow-up

Pacemaker
Follow-up
Alpay Çeliker MD.
Hacettepe University
Department of Pediatric Cardiology
3rd International Summer School on Cardiac
Arrhythmias, 9-12 September, Eskişehir
Organization
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Regular follow-up schedule
Pacemaker record files
X-ray
ECG
Telemetry units
Pacemaker Follow-up:
Objectives
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Adjust the pacing system
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Maximize the benefits of pacing therapy
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Predict impending pacemaker system
failure before the patient is at risk
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Ascertain the nature of malfunction
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Look for accompanying complications
PATIENT
TELEMETRY
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ECG&TELE
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THRESHOLDS
INTRINSIC AMPLITUDES
PACEMAKER DEPENDENCY
PACING RATIO
HISTOGRAMS
PACING EFFICACY
LEAD PROBLEMS
HOLTER, EXERCISE TEST
PHYSICAL EXAM
ECHO
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EXERCISE PERFORMANCE
MAXIMUM HEART RATE
DETECT CAPTURE AND SENSING PROBLEMS
Pacemaker Follow-up
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Patient evaluation
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History
Physical examination
Chest x-ray
Echocardiography
Pacing system evaluation
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Surface ECG
Telemetric control of pacemaker
Holter monitoring
Treadmill testing
History
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Palpitations
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Weakness, fatigue, malaise, dyspnea
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Pacemaker syndrome, capture failure, inappropriate
programming, cardiac or pulmonary disease
Hiccups
Syncope, presyncope
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Rapid ventricular rate, PMT, intrinsic tachycardia
Pacemaker syndrome, capture problem, inhibition due to
oversensing
Cough, chest pain
Radiologic Evaluation
Pacemaker Interrogation
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Administrative data verification
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Programmed data control
Examine the pacing&sensing parameters
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Name, implant date
Capture threshold
Voltage measurements
Battery&lead measurements
Overview the memorized data
Capture Thresholds
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Automatic or manual measurements
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Voltage or pulse width thresholds
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Pacing rate > spontan rate during test
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Test during coughing and deep respiration to
detect malfunction
Absence of PM Stimuli or
Capture
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Intrinsic rate > pacing rate
Hysteresis
Very tiny bipolar stimuli
Lead problems
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Pulse generator problems
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Fracture, loose connection
EOL, failure
Electromagnetic interference
Oversensing
Atrial Noncapture
Ventricular Noncapture
Sensing Thresholds
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Automatic or manual measurements
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Print-out of intracardiac
electrocardiogram
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Needs for spontaneous atrial or
ventricular rhythm
Undersensing
Undersensing
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Low amplitude EGM due to poor lead
position
Lead dislodgement
Lead malfunction
Metabolic or toxic causes
Development of new bundle branch
block
Myocardial infarciton near the electrode
tip
Oversensing
Causes of Oversensing
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Ventricular
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T wave
Crosstalk
Myopotentials
False signals
Atrial
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Far-field R wave
Myopotentials
False signals
Change in Pacing Rate
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Battery depletion
Runaway pacemaker
Component failure
Oversensing
External effects on battery
Phantom or wrong programming
Signs of Lead Fracture
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No stimuli
Stimuli without capture
Oversensing of false signals
Permanent or intermittant high lead
impedance
Maneuvers
X-ray
Testing of Specific
Functions
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Check for crosstalk
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Evaluate the VA interval
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Examine rate adaptive parameters
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Hysteresis, sleep rate
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Automatic mode switching
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Histogram settings
Rate Adaptive Pacemaker
Rate Histogram
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Assess rate response settings
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Assess high rate events
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Evaluate percent pacing versus sensing
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Determine if a change in disease state condition
has occurred
Atrial Pace/sense Histogram
Physical Examination
Pacing System
Pocket
•Infection
•Erosion
•Migration
•Twiddler’s syndrome
•Muscle stimulation
•Chronic pain
Vascular System
•Venous thrombosis
•Intracardiac thrombus
•Lead Endocarditis
•Tricuspid valve
entanglement
•TR
Leads
•Displacement
•Perforation
•Diaphragmatic
pacing
Lead Endocarditis
Venous Obstruction
<obstruction
Pacemaker Syndrome
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Dizziness
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Presyncope
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Chest tightness
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Shortness of breath
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Neck pulsations
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Apprehension/malaise
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Fatigue
PMT
Conclusions I
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Long rhythm strips with markers and IEGM’s
may needed for correct diagnosis
12 lead paced ECG is very valuable
Know the timing cycles
Do not attribute patient symptoms to age,sex
or underlying heart disease
Do not leave the pacemaker at factory
settings, since every patient has different
necessities.
Conclusions II
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Make every effort to prolong battery life
The other purpose of pacing is optimization of
quality of life
Optimal AV delay can not be predicted
Test the retrograde VA conduction
Keep the records carefully
Be obsessive in pacemaker dependent
patient