2008 terni, workshop interattivo, tecniche di impianto dei pacemaker in urgenza

1. Principi di tecnica di impiantoPrincipi di tecnica di impianto
del Pacemaker temporaneodel Pacemaker temporaneo
in urgenzain urgenza
Stefano Nardi, MD, PhD
Toracich and Cardio-Vascular Departement
Divison of Cardiology
Arrhythmia, EP Center and Cardiac Pacing Unit
Santa Maria General Hospital, TerniSanta Maria General Hospital, Terni

2. BRADIARITMIABRADIARITMIA
EMERGENZAEMERGENZA
 SINTOMATICA (Sincope, Lipotrimia, Dispnea)SINTOMATICA (Sincope, Lipotrimia, Dispnea)
 FC < 40 BMFC < 40 BM
 GRAVITA’ DELLA CARDIOPATIA PRESENTEGRAVITA’ DELLA CARDIOPATIA PRESENTE

3. BRADIARITMIEBRADIARITMIE
MALATTIE ATRIALIMALATTIE ATRIALI
BLOCCHIBLOCCHI
ATRIOVENTRICOLARIATRIOVENTRICOLARI
BLOCCHIBLOCCHI
INTERVENTRICOLARIINTERVENTRICOLARI

4. Malattie AtrialiMalattie Atriali
Bradicardia Sinusale MarcataBradicardia Sinusale Marcata
Blocchi Seno-Atriali II° e III° sintomaticiBlocchi Seno-Atriali II° e III° sintomatici
Sindrome bradi-tachi (Pause lunghe)Sindrome bradi-tachi (Pause lunghe)
Eziologia
IMA inferioreIMA inferiore
Patologie Extra-cardiachePatologie Extra-cardiache
(neuromuscolari – emorragie digestive)(neuromuscolari – emorragie digestive)
FarmaciFarmaci
ß-bloccanti, Digoxina, Verapamil, etcß-bloccanti, Digoxina, Verapamil, etc
Ipertono VagaleIpertono Vagale

5. MALATTIE ATRIALIMALATTIE ATRIALI
BRADICARDIA SINUSALE MARCATABRADICARDIA SINUSALE MARCATA
TERAPIATERAPIA
• Atropina – 0.5 mg e.v., ripetibileAtropina – 0.5 mg e.v., ripetibile
• IsoproterenoloIsoproterenolo
• Stimolazione TemporaneaStimolazione Temporanea

6. BLOCCHI ATRIO-VENTRICOLARIBLOCCHI ATRIO-VENTRICOLARI
BAV II E III GRADO SINTOMATICIBAV II E III GRADO SINTOMATICI
EZIOLOGIAEZIOLOGIA
Cardiopatia Organica CronicaCardiopatia Organica Cronica
((Ischemica, Reumatica, Congenita, DCM)Ischemica, Reumatica, Congenita, DCM)
IMAIMA
FarmaciFarmaci
((ß-bloccanti, Digoxina, Verapamil, etc)ß-bloccanti, Digoxina, Verapamil, etc)
Ipertono VagaleIpertono Vagale

7. BAV II GRADOBAV II GRADO
BAV III GRADOBAV III GRADO

8. BAV AVANZATOBAV AVANZATO
INDICAZIONI AL TRATTAMENTOINDICAZIONI AL TRATTAMENTO
P M T E M P O R A N E O
S IN T O M A T IC O
A T R O P IN A E .V . 0 .5
R IP E T IB IL E
A S IN T O M A T IC O
O S S E R V A Z IO N E
Q R S S T R E T T O
P M T E M P O R A N E O
Q R S L A R G O
B A V T O T A L E
B A V II G R A D O A V A N Z A T O

9. BLOCCHI INTERVENTRICOLARIBLOCCHI INTERVENTRICOLARI
ACUTIACUTI
EZIOLOGIAEZIOLOGIA
IMAIMA
Indicazioni alla Stimolazione TemporaneaIndicazioni alla Stimolazione Temporanea
Blocco TrifascicolareBlocco Trifascicolare
Blocco Bifascicolare (BBD+EAS, BBD+EPS)Blocco Bifascicolare (BBD+EAS, BBD+EPS)
BAV I° + EAS o EPSBAV I° + EAS o EPS

10. IMA INFERIOREIMA INFERIORE
P M T E M P O R A N E O
A T R O P IN A E V
B L O C C O S A
B R A D . G IU N Z IO N A L E
B R A D . S IN U S A L E
B A V II T IP O 1
P M T E M P O R A N E O
B A V II T IP O 2
B A V T O T A L E
S IN T O M A T IC O
F C < 4 0 B M
A T R O P IN A E V
O S S E R V A Z IO N E
A S IN T O M A T IC O
B R A D IA R IT M IA

11. IMA ANTERIOREIMA ANTERIORE
P M T E M P O R A N E O
B A V I I T I P O 2
B A V T O T A L E
A L T E R N A N Z A D I B B D E B B S
B L O C C O B I O T R IF A S C IC O L A R E
S I N T O M A T I C O
A S I N T O M A T I C O
P M T E M P O R A N E O
A T R O P IN A E V
B R A D . S I N U S A L E
B L O C C O S A
B R A D . G I U N Z I O N A L E
B A V I I T IP O 1
A S I N T O M A T I C O
B R A D I A R I T M I A

12. Stimolazione temporanea in
urgenza anche nelle tachiaritmie?

13. TORSIONE DI PUNTATORSIONE DI PUNTA
QTc long SyndromeQTc long Syndrome
SINDROME di Jerwell-Lange-Nielsen (con Sordità)SINDROME di Jerwell-Lange-Nielsen (con Sordità)
SINDROME DI Romano-Ward (senza Sordità)SINDROME DI Romano-Ward (senza Sordità)
FORME ACQUISITEFORME ACQUISITE
Disturbi Elettrolitici (IPOK+ IPOMG+)Disturbi Elettrolitici (IPOK+ IPOMG+)
Farmaci (Chinidina, Amiodarone, Sotalolo, Ibutilide, etc)Farmaci (Chinidina, Amiodarone, Sotalolo, Ibutilide, etc)
Aritmie Ipocinetiche (BAV TOTALE)Aritmie Ipocinetiche (BAV TOTALE)

14. TORSIONE DI PUNTATORSIONE DI PUNTA
ALGORITMO TERAPEUTICOALGORITMO TERAPEUTICO
E L E T T R O S T I M O L A Z I O N E T E M P O R A N E A
1 0 0 - 1 2 0 / M I N : A T R I A L E O V E N T R I C O L A R E
T d P
I N C R E M E N T O D E L L A F C
I S O P R O T E R E N O L O : 0 . 0 1 - 0 . 0 2 u g / k g / m in
A T R O P I N A E V : B O L O 0 . 5 m g , R I P E T I B I L E O G N I 1 0 '
M E T O P R O L O L O : F O R M A C O N G E N I T A E D A A . T R I C I C L I C I
T d P
E V E N T U A L E C O R R E Z I O N E
D E L D I S T U R B O E L E T T R O L I T I C O
M g S O 4 E V : 1 - 2 G . I N 5 - 1 0 ' , I N F U S I O N E D I 1 - 2 G H P E R 4 - 6 H
K C L : 1 0 m E q / h F I N O A L L A C O R R E Z I O N E D E L L O S Q U I L I B R I O
T O R S I O N E D I P U N T A ( T d P )

15. QUALE STIMOLAZIONE
TEMPORANEA ?
EPICARDICA
TRANSESOFAGEA
TRANSTORACICA
TRANSVENOSA

16. PACEMAKER TEMPORANEO

24. ECG con stimolazione temporanea

25. Complications
• Pacing Failure
– Failure to Output
– Failure to Capture
• Pseudomalfunction
• Sensing Failure
– Oversensing
– Undersensing
• Operative Failure
Transvenous Pacemaker (TVP)

26. Failure to Output
• Occurs when no PM spike is present
• This may be due to battery failure, lead fracture,
a break in lead insulation, oversensing (inhibiting),
poor lead connection at the take-off from the PM,
and "cross-talk" (when A output is sensed by a V
lead in a dual-chamber PM).
Transvenous Pacemaker

27. Failure to Capture
A spike not followed by either a V complex
- lead fracture
- lead dislodgement
- elevated PM threshold
- MI at the lead tip
- certain AADs (eg, flecainide)
- metabolic abnormalities (hyper-k+
, acidosis, alkalosis)
- cardiac perforation
- poor lead connection at the take-off from the
generator
- improper amplitude or pulse width settings.
Transvenous Pacemaker

28. Sensing
• Definizione
- capacità del PM di percepire un segnale elettrico
intrinseco, in funzione dell’ampiezza, dello Slew-rate,
della frequenza del segnale e della posizione degli
elettrodi.
• Sensibilità programmata
- Indica il minimo segnale intracardiaco che il PM
percepisce per attivare la risposta del PM
(inibito o triggerato).

29. 5 mV
2 mV
1 mV
Sensing
• La sensibilità programmata determina la capacità
del dispositivo di rilevare dei segnali.

30. 5 mV
2 mV
1 mV
Sensing
• Quando si programma la sensibilità, se si
diminuisce il suo valore, si rende il PM più
sensibile (“sente” meglio).

31. 5 mV
2 mV
1 mV
Sensing
• Se la sensibilità programmata è troppo bassa
il dispositivo “sente” troppo

32. 8 mV
6 mV
4 mV
2 mV
0 mV
Onda R 7 mV Onda R 3 mV
Pacemaker programmato a 4 mV
Sensing
rilevata non rilevata

33. Pacemaker programmato a 2 mV
8 mV
6 mV
4 mV
2 mV
0 mV
Entrambe le onde vengono rilevate
Onda R 7 mV Onda R 3 mV
Sensing

34. Oversensing Ventricolare
Frequenza base
di stimolazione
Viene sentito un evento non
corrispondente a onda R e
viene inibito il pacemaker
Pause prolungate tra
uno stimolo e il
successivo

35. Oversensing
• When a PM incorrectly senses electrical activity
and is inhibited from correctly pacing.
• This may be due to muscular activity (particularly
oversensing of the diaphragm or pectoralis
muscles), electromagnetic (EM) interference, or
lead insulation breakage.
Transvenous Pacemaker

36. Undersensing Ventricolare
Frequenza base
di stimolazione
Onde R non sentite. Il pacemaker
genera uno stimolo inappropriato

37. Undersensing
• When a PM incorrectly misses intrinsic
depolarization and paces despite intrinsic activity.
• This may be due to poor lead positioning, lead
dislodgment, magnet application, low battery
states, or MI.
• Management is similar to that for other types of
failures.
Transvenous Pacemaker

38. • A final category of PM failures is termed operative
• This includes malfunction due to mechanical
factors, such as PNX, pericarditis, infection, skin
erosion, hematoma, lead dislodgment, and venous
thrombosis.
• Treatment depends on the etiology.
Transvenous Pacemaker (TVP)

43. (and electrodes if Demand or Back-up Pacing)
• Stat-Padz application should
be Anterior/Posterior
• 3-lead ECG electrodes must
be placed also
Think of 2 pieces of white bread and you
are making a myocardial sandwich
Transcutaneous PM (TCP)

44. Access Pacer (Green) mode
The Pacer mode is accessed by
turning the Selector Switch
counter-clockwise
• Milliamps are the type of current
which are utilized in this mode
• No AED capability or
ANALYZE button can be used in
this mode
Transcutaneous PM (TCP)

45. Pacer Mode
• Pacer markers (PPM) indicate
the rate set to attempt to capture
the ventricle
• Default settings of 70 PPM and
0 mA are displayed upon access
of Pacer Mode
• To increase or decrease pacer
marker (PPM) turn the Pacer
Rate Dial
Transcutaneous PM (TCP)

46. Pacer Mode: Output Dial
• Turn the Pacer Output dial to
adjust the level of discharged
milliamps.
• If capture is achieved, the PPM
will have a wide complex
reflecting ventricular
contraction following the thin
PPM rate marker
Transcutaneous PM (TCP)

47. Pulse Duration
• Pulse duration is the time of impulse stimulation.
• Early TCPs used short (1-2 ms) duration impulses.
Such impulses resembled the action potential (AP)
and preferentially stimulated skeletal muscle.
• In contrast, cardiac muscle APs are much longer,
requiring 20-40 msec to reach maximum.
Transcutaneous PM (TCP)

48. Current
• Using a longer pulse duration and larger electrodes
permits pts to tolerate higher applied current.
• 100 mA of current applied over an average (50 Ώ
resistance) chest for 20 ms will deliver 0.1 J. This is
well below the 1-2 J required to cause an
uncomfortable tingling sensation in the skin.
• The force of skeletal muscle contraction, not the
electric current, determines TCP discomfort. Current
TCPs are capable of delivering up to 140-200 mA
tolerably.
Transcutaneous PM (TCP)

49. Definition of Capture:
Electrical and Mechanical
• Electrical capture: Every PPM
(pacer rate indicator) is followed
by a larger complex (QRS) which
indicates ventricular contraction
• Mechanical capture: When an
associated pulse is created with
the electrical capture. Pulse rate
should be PPM rate
• Once electrical and mechanical
capture has been confirmed, dial
the mA up 10% from capture
threshold as a safety margin
Transcutaneous PM (TCP)

50. Pacing Mode:
Ability to Perform 3 Types of Ventricular Pacing
1.) Demand Pacing:
Most frequent form of ventricular pacing. The PPM is set above
patient’s rate (or lack thereof) and the Pacer Output dial is turned to
increase the mA in attempt to obtain capture and pace the ventricles.
2.) Stand-by Pacing:
Setting the PPM and Pacer output at a back-up rate less than a
patient’s intrinsic heart rate. The PPM will initially be set above the
patients heart rate and pacer output (mA) is increased to achieve 100%
capture. The PPM is then decreased to desired rate below the patients
intrinsic heart rate. Should the HR drop, the stand-by pacer will
initiate impulses and begin to pace.
Transcutaneous PM (TCP)

51. 3.) Asynchronized Pacing:
Rarely used. This form of pacing is performed when no ECG electrodes can be
placed due to burns, trauma or interference. The async on/off softkey button is
pressed and aysnc mode is displayed. No PPM or electrical capture will be
seen on the screen. Mechanical capture will only be proven by palpating a
pulse if one is achieved
Pacing Mode:
Ability to Perform 3 Types of
Ventricular Pacing
Transcutaneous PM (TCP)