Rate - Interval Conversion Table - Springer978-3-642-58810-5/1.pdf · Rate - Interval Conversion Table Rate Cycle length Rate Cycle length (BPM) (ms) (BPM) (ms) 20 3000 215 279 25

Rate - Interval Conversion Table

Rate Cycle length Rate Cycle length (BPM) (ms) (BPM) (ms) 20 3000 215 279 25 2400 220 273 30 2000 225 267 35 1714 230 261 40 1500 235 255 45 1333 240 250 50 1200 245 245 55 1091 250 240 60 1000 255 235 65 923 260 231 70 857 265 226 75 800 270 222 80 750 275 218 85 706 280 214 90 667 285 211 95 632 290 207 100 600 295 203 105 571 300 200 110 545 305 197 115 522 310 194 120 500 315 190 125 480 320 188 130 462 325 185 135 444 330 182 140 429 335 179 145 414 340 176 150 400 345 174 155 387 350 171 160 375 355 169 165 364 360 167 170 353 365 164 175 343 370 162 180 333 375 160 185 324 380 158 190 316 385 156 195 308 390 154 200 300 395 152 205 293 400 150 210 286

Rate (BPM or m i n 1 ) =

Cycle length (ms) =

60,000 Cycle length (ms)

60,000

Rate (BPM or m i n 1 )

W. Fischer • Ph. Ritter, Cardiac Pacing in Clinical Practice

Springer-Verlag Berlin Heidelberg GmbH

W. Fischer • Ph. Ritter

Cardiac Pacing in Clinical Practice With a Foreword by D. Hayes

With 324 Figures in 547 Parts, 8 Tables, and Glossary

Springer

Dr. med. Wilhelm Fischer Innere Abteilung, Krankenhaus Peißenberg Hauptstraße 55-57, D-82380 Peißenberg

Dr. med. Philippe Ritter Dept. de Stimulation Cardiaque d'Electrophysiologie Centre Chirurgical Val d'Or, F-92210 Saint Cloud

Translator: Rodolphe Ruffy

Translation of the Second German Edition 1997, and of the French Edition 1997 W. Fischer, Ph. Ritter: Praxis der Herzschrittmacher-Therapie 2. Auflage 1997, ISBN 3-540-60264-X Ph. Ritter, W. Fischer: Pratique de la Stimulation cardiaque, Edition 1997 I S B N 978-3-642-63741-4

Library of Congress Cataloging-in-Publication Data Fischer, Wilhelm. 1949- [Praxis der Herzschrittmachertherapie. English] Cardiac pacing in clinical practice / W. Fischer, Ph. Ritter; with a foreword by David Hayes ; [translator, Rodolphe Ruffy]. - - ist ed. p. cm. "Translation of the second German edition 1997" - T.p. verso Includes bibliographical references and index. I S B N 978-3-642-63741-4 I S B N 978-3-642-58810-5 (eBook) DOI 10.1007/978-3-642-58810-5 1. Cardiac pacing. I. Ritter, Ph., 1949- . II. Title. [ D N L M : 1. Pacemaker, Artificial. 2. Car­diac Pacing, Artificial. WG 26 F529P 1998a] RC684.P3F5513 1998 617.4 120645--dcZT D N L M / D L C for Library of Congress 98-12136 CiP

This work is subject to copyright. A l l rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illus­trations, recitation, broadcasting, reproduction on microfilm or in other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9,1965, in its current version, and permission for use must always be obtained from Springer-Verlag. Violations are liable for prosecution under the German Copyright Law.

© Springer-Verlag Berlin Heidelberg 1998 Originally published by Springer-Verlag Berlin Heidelberg New York in 1998

The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.

Product liability: The publisher cannot assume any legal responsibility for given data, especially as far as directions for the use and the handling of chemicals and technical devices are concerned. This information can be obtained from the instructions on safe laboratory practice and from the manufacturers of chemical and laboratory equipment.

Cover Design: E Steinen-Broo, eSTUDIO C A L A M A R , E-17494 Pau Typesetting: FotoSatz Pfeifer GmbH, D-82166 Gräfelfing

SPIN: 10769266 22/3111 - 5 4 3 2 1 - Printed on acid-free paper

Dedicated to our families

Foreword

Pacemaker technology has evolved rapidly over the nearly 40 year history of the device. On several occasions over the past decade, I have heard individuals involved in some aspect of cardiac pacing, state that pacemaker technology had reached the end of it's developmental stage and no further improvements should be anticipated. Conversely, I've also heard many far-sighted individuals discuss potential pacemaker features and applications that seemed far-fetched. The lat­ter group have been vindicated as pacemaker technology continues to advance. In such a dynamic field, it is crucial that state-of-the-art information exists and that it is provided in an understandable format.

In the course of our medical library acquisitions, many of us have purchased a medical textbook based upon the title that promises "state-of-the-art" infor­mation, only to be disappointed when the text fails to adequately deliver the expected information. Anyone who reads "Cardiac Pacing in Clinical Practice<~ whether cover-to-cover or used as a reference for management of clinical pacing problems, will find that the text fulfills all expectations. Drs. Ritter and Fischer have provided a comprehensive, understandable, state-of-the-art guide to clini­cal management of the pacemaker patient that can be appreciated by both physi­cian and allied professional.

Preparation of such a comprehensive text by only two authors is an arduous task. However, the benefits of limited authorship is evident as one reads this book. There is a consistent style throughout in both text and graphics. This avoids redundancy and facilitates comprehension. In addition, the consistent writing style allows the authors to build on complexity from the beginning to end of each chapter. For example, the description of pacemaker system implan­tation encompasses the most basic portions, such as attaching the lead to the pulse generator, as well as less commonly encountered aspects such as pace­maker implantation in the cardiac transplant patient.

The extensive clinical experience of the authors is clearly evident. Every chap­ter is complete and up-to-date, from the description of the newer combipolar pacing configuration to new indications for pacing, and the extensive glossary and index makes it easy to seek answers to specific clinical questions. Readers who are involved in the day-to-day care of the pacemaker patient will find sev­eral chapters particularly helpful. The extensive discussion of pacing modes and their application allows a logical approach to individualizing pacemaker pre-

VIII Foreword

scriptions. An exhaustive guide to patient follow-up and programming is pro­vided. Thorough knowledge and understanding of this text should allow provid­ers to avoid complications in their practice. However, in the event that a patient with a complication is referred for treatment, practical management guidelines for everything from hematoma formation to AccufixTM lead management is included.

It is highly likely that this text will prove to be an enduring source of informa­tion in the field of cardiac pacing, providing an inclusive guide with an interna­tional perspective. Those of us dedicated to providing expert care in the arena of cardiac pacing, are hopeful that many countries will eventually develop and apply standards of care for the paced patient. Ritter and Fischer provide a work that could serve as a basis for such standards.

David L. Hayes, MD

Acknowledgements

This book is the result of an intensive collaboration between scientists, engi­neers, and physicians from separate institutions, cities, countries, and conti­nents.

Ms. Monika Schrimpf of Springer-Verlag deserves a great deal of credit for her assistance and organization and Ms. Ursula Appl, Dipl.-Ing., for the excellent and expert translation she provided the authors with.

Furthermore, we gratefully acknowledge the invaluable assistance of Prof. Werner Irnich; both his counsel and his review of the whole book with regard to its physics and correct use of terminology are much appreciated.

We owe many thanks to Ulf H. Knabe, MD, for his helpful input and proof­reading of the sections on surgery and to Martin R. Locher for his valuable edito­rial contributions to the German edition during its extensive revision.

Thanks are also due to Kaoru Kunisada, MD, Japan, for his fine cooperative efforts.

Special thanks also go to Bernard Dodinot, MD, Editor in Chief of Stimucoeur Stimulography, for giving us permission to reproduce a great number of the fig­ures included in this book; to Rodolfo Ruffy, MD, Cardioscript International, for the very professional translation of this book from the German and French, and for his corrections and advice; to David Hayes, MD, for kindly writing the fore­word; and to Jacques Mugica, MD, and Prof. Claude Daubert, MD, for their great help in making this work possible.

Philippe Ritter Wilhelm Fischer st. Cloud Peissenberg

Contents

Introduction: A Short History of Cardiac Pacing. . . . . . . . . . . . . . . . . . . . . . 1

1 Brief Review of the Anatomy, Electrophysiology and Pathophysiology of the Cardiac Conduction System

1.1 Anatomy and Electrophysiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 The Sinoatrial Node .............................................. 5 The Atrioventricular Node. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 The His Bundle .................................................. 7 The Purkinje Network. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Automatic Foci. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Anterograde and Retrograde Conduction ............................ 8 Refractory Periods of the Heart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

The Absolute Refractory Period .................................. 9 The Relative Refractory Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Refractory Periods in Various Cardiac Tissues . . . . . . . . . . . . . . . . . . . . .. 10

1.2 The Main Depolarization and Conduction Disorders. . . . . . . . . . . . . . . 11

Sinus Node Disease (the Sick Sinus Syndrome) . . . . . . . . . . . . . . . . . . . . . . . . 11

Chronotropic Incompetence ..................................... 11

Atrial Tachyarrhythmias ........................................ 11

Electrophysiological Testing ..................................... 11

Atrioventricular and Intraventricular Conduction Disorders ............ 14

Atrioventricular Block (AVB) .................................... 14

Bundle Branch Blocks .......................................... 16

2 General Technical Concepts

2.1 How to Stimulate the Heart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 19

Basic Principles of Electricity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 20

Pacing Threshold. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 21

Influence of Pacing Rate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 24 Influence of Drugs and Metabolic Disorders. . . . . . . . . . . . . . . . . . . . . . .. 25 Influence of Degree of Fibrosis ................................... 25 Influence of Electrode Configuration on Pacing Impedance

and Pacing Threshold. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 25

XII Contents

Influence of Polarity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 26 Influence of the Pacing Stimulus Waveform ........................ 26

Sensing......................................................... 27 The Frequency Spectrum. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 27 The Slew Rate ................................................. 28

Signal Amplitude .............................................. 30

2.2 The Pulse Generator .......................................... 33 Sources of Pacing Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 33 The Pacemaker Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 36 Pacemaker Longevity ............................................. 38

2.3 Programming and Telemetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 40 Programming. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 40 Telemetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 43

2.4 The Pacing Lead. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 44 The Connector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 44 The Conductor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 45 The Insulation ................................................... 45 The Electrode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 46 Fixation Methods. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 47 Unipolarity Versus Bipolarity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 48

Combipolar Concept. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 53

3 The Pacing Modes

J.1 The International Code . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 54

3.2 The Various Types of Pacemakers and Their Programmable Functions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 57

Terminology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 59 Demand Versus Fixed Rate Pacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 59 Rate Versus Pacing Cycle and Versus Escape Interval ................ 61

Single Chamber Pacemakers ....................................... 62 SSI Mode Without Rate Responsiveness. . . . . . . . . . . . . . . . . . . . . . . . . . .. 62 The SST Mode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 75 The Asynchronous (SOO) Mode. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 78

Dual Chamber Pacemakers ........................................ 78 The DDD Mode. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 79 Automatic Mode Switch AAI/DDD ................................ 106

The DDI Mode. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 106

The DOO Mode. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 112

Other Modes of Dual Chamber Pacing ............................ , 112

The VDD(R) Mode . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 116

Rate Responsive Pacemakers ....................................... 120

The Various Sensors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 121 Dual Sensor Pacemakers ........................................ 138

Contents XIII

Integration of Rate Responsiveness in Single and Dual Chamber Pacemakers ................................................... 139

Antitachycardia Pacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 144 Atrial Tachyarrhythmias Prevention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 144

Protection Against Sustained Atrial Tachyarrhythmias . . . . . . . . . . . . . .. 146 Multimode Switch .............................................. 155 Role of Antitachycardia Pacing in Permanent Cardiac Pacing ......... 155

4 Indications for Permanent Pacing and Choice of Pacemaker. . . . . . . . .. 166

4.1 History and Investigation ................•..................... 167 Clinical History ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 167 Physical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 168

Resting and Ambulatory Electrocardiogram. . . . . . . . . . . . . . . . . . . . . . .. 168 Exercise Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 168 Atropin Test . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 168 Carotid Sinus Massage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 169 Upright Tilt-Table Testing ....................................... 169 Invasive Testing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 169

4.2 Temporary Cardiac Pacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 170 Indications ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 170 Techniques of Temporary Pacing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 172

Mechanical Stimulation ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 172 Transcutaneous Electrical Stimulation. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 172 Transesophageal Stimulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 173

Endocardial Stimulation ........................................ 173 Transthoracic Pacing ........................................... 174

4.3 Permanent Cardiac Pacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 175 Pacing Indications Based on Abnormal Electrocardiogram. . . . . . . . . . . . .. 175

Sino-Atrial Dysfunction ......................................... 175 Atrioventricular Block .... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 176 Bi - and Trifascicular Blocks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 178 Bradyarrhythmia in the Presence of Atrial Fibrillation ... . . . . . . . . . . .. 178

Indications for Permanent Pacing in the Pediatric Patient. . . . . . . . . . . . . .. 179 Indications for Implantation of a Permanent Pacemaker for Sino-Atrial and

Intraventricular Conduction Disturbances After Acute Myocardial Infarction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 179

Indications for Permanent Pacing in Cases of Syncope with Normal or Near Normal Electrocardiogram . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 180

Intrahisian Block. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 180 Carotid Sinus Syndrome ........................................ 180 Vaso-Vagal Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 181

Unexplained Syncope ............................................. 181

Bradyarrhythmias Following Heart Surgery .......................... 182 New Indications .................................................. 183

XIV Contents

Complete Heart Block Induced by His Bundle Ablation .............. 183

Obstructive Hypertrophic Cardiomyopathy ........................ 183

Prevention of Atypical Atrial Flutter .............................. 183

Non-Obstructive, Dilated Cardiomyopathy ......................... 184

4.4 Choice of Pacemaker Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 185

Physiology of the Paced Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 185

Heart Rate Increase with Exercise. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 186

Atrioventricular Synchrony . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 186

Optimization of Atrioventricular Synchrony. . . . . . . . . . . . . . . . . . . . . . .. 189

Ventricular Contraction Synchrony ... . . . . . . . . . . . . . . . . . . . . . . . . . . .. 192

Atrial Resynchronization ........................................ 195

Advantages and Disadvantages of Various Pacing Modes ............... 196

Pure Atrial Modes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 196

Pure Ventricular Modes ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 198

The Dual Chamber Modes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 199

Pacing Mode Selection ............................................ 200

For Pure Sinus Node Dysfunction ................................. 200

For Isolated Atrioventricular Block ............................... 201

For Binodal Disease (Sinus Node Dysfunction Plus at Least First Degree AV Block) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 201

For Chronic Atrial Fibrillation with Ventricular Bradyarrhythmia ..... 201

For Carotid Sinus Syndrome or Vaso-Vagal Syndrome ............... 201

5 Implantation Techniques

5.1 Preparation of the Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 203

Patient Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 203

Requirements of the Procedure ..... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 203

Implant Facilities ................................................. 204

The Implantation Site ............................................. 204

Preoperative Preparation .......................................... 204

Choice of Implant Instrumentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 205

Anesthesia ...................................................... 206

5.2 System Implantation .......................................... 206

Venous Access ................................................... 206

Lead Placement .................................................. 211

Intraoperative Measurements ...................................... 218

Sensing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 219

Pacing ........................................................ 222

Verification of Absence of Diaphragmatic Pacing and Lead Stability . . . . .. 222

Attachment and Connections of the Leads. . . . . . . . . . . . . . . . . . . . . . . . . . .. 223

The Post-Implant Period. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 227

5.3 Pacemaker Implant in the Pediatric Patient. . . . . . . . . . . . . . . . . . . . . .. 228

5.4 Pacemaker Implantation in the Cardiac Transplant Patient ......... 229

Contents XV

5.5 Pacemaker Implantation in Special Cases. . . . . . . . . . . . . . . . . . . . . . . .. 230

Presence of a Left Superior Vena Cava ............................... 230

Right Heart Chambers Dilatation ................................... 230

Tricuspid Annuloplasty or Prosthetic Tissue Valves .... . . . . . . . . . . . . . . .. 231

Planned Cardiac Surgery .......................................... 231 Biatrial Pacing ................................................... 231

Left Ventricular Pacing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 234

6 Complications 6.1 Intra- and Postoperative Complications. . . . . . . . . . . . . . . . . . . . . . . . .. 237

Complications at the Implant Site .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 238

Hematoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 238 Pectoral Stimulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 238

Infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 239 Complications Related to Vascular Access ............................ 239

Lead Implantation in a Left -Sided Chamber . . . . . . . . . . . . . . . . . . . . . . .. 239 Pneumothorax, Hemothorax and Hemomediastinum . . . . . . . . . . . . . . . . 240 Air Embolism ................................................. 241 Venous Thrombosis ............................................ 241

Cardiac Complications ............................................ 241 Rhythm Disturbances. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 241

Asystole ...................................................... 242 Myocardial Perforation and Tamponnade . . . . . . . . . . . . . . . . . . . . . . . . .. 242

Complications Related to the Pacing System .......................... 243

Diaphragmatic Pacing .......................................... 243 Lead Dislodgment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 243

Pacing and Sensing Threshold Rise ............................... 245

Postoperative Autonomic Dysregulation ............................. 246

6.2 Late Complications ........................................... 246 Local or Regional Complications Related to the Site of Implantation ...... 246

Infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246 Migration of the Pacemaker Can. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 247 Pacemaker Pocket Erosion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 247 Venous Thrombosis ............................................ 248

Lead-Related Complications ....................................... 249 Secondary Dislodgment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 249 Changes in Pacing and Sensing Threshold ......................... 249

Insulation Failure .............................................. 250 Interruption of Electrical Continuity . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 252

Mechanical Complication Related to the Lead ...................... 255 Recommendations Relative to the Accufix and Encor Leads. . . . . . . . . .. 255

6.3 Complications Related to the Pulse Generator or the Programmed Mode. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 256

Sources of Interference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 256

XVI Contents

Endogenous Interference. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 256 Exogenous Interfurence ......................................... 257

Changes in Pacing Rate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 262 Shut Down ...................................................... 262 Battery Depletion ................................................ 262

7 Patient Follow-Up

7.1 General Principles

7.2 Simple Follow-Up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 265 History ......................................................... 265

Syncope and Near Syncope ...................................... 265 Dyspnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266 Palpitation .................................................... 267 Chest Pain .................................................... 268 Pectoral Stimulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268 Diaphragmatic Stimulation ...................................... 269

Physical Examination ............................................. 269 Resting Electrocardiogram. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269

Verification of Proper Pacing Function ............................ 271 Verification of Proper Sensing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 272 Elective Replacement Determination. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 272

Transtelephonic Interrogation ...................................... 274

7.3 Comprehensive Follow-Up ..................................... 274

Telemetry .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 275 Is the Device Programming Identical to What It Was at the Last Visit? .. 275 Battery Status and End of Life Indicators. . . . . . . . . . . . . . . . . . . . . . . . . . . 280 Information Stored in the Pacemaker's Memory .................... 284 Electrical Integrity of the Lead System. . . . . . . . . . . . . . . . . . . . . . . . . . . .. 298 Intracardiac Events Displayed by the Pacemaker .................... 302 Economy of Energy Consumption ................................ 304 Final Interrogation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 304 Results ofLong-Term Diagnostic Data ............................. 305

8 Practical Guide to Programming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309

8.1 Programming of a Single Chamber Pacemaker. . . . . . . . . . . . . . . . . . . .. 311 Sensing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 311 Pacing .......................................................... 321 Escape and Pacing Interval Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 325 Refractory Period ................................................ 326

8.2 Programming of a Dual Chamber Pacemaker . . . . . . . . . . . . . . . . . . . .. 331

Identification of the Atrial and Ventricular Pacing Spikes . . . . . . . . . . . . . .. 331 Atrial Sensing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 331

Contents XVII

Ventricular Pacing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 337 Atrial Pacing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 337 Ventricular Sensing ............................................... 344 Atrioventricular Crosstalk ......................................... 349 Ventriculo-Atrial Crosstalk ........................................ 349 AVD After Paced Versus Sensed P Wave (AV Hysteresis) ................ 349 Atrioventricular Delay (AVD) ...................................... 356 The Postventricular Atrial Refractory Period (PVARP) ................. 359 Other Parameters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 362

9 Pulse Generator and/or Lead Replacement

9.1 Reasons for Replacement of the Implanted Material. . . . . . . . . . . . . . .. 368 Indications for Replacement of the Pulse Generator . . . . . . . . . . . . . . . . . . .. 368 Indications for Lead Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 369 Grounds for Changing the Pacing Mode .............................. 369

9.2 Reintervention Techniques ..................................... 370 Preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 370 The Procedure ................................................... 370 Connection Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 373 Reinterventions in Presence ofInfection ............................. 375

General Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 375 Lead Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 377

10 Conclusions .................................................. 379

Appendix ................... " ........... " ..................... 381

General The Magnet Modes ............................................... 381 Medical Emergencies in Paced Patients .............................. 381 Questions Asked by Paced Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 382

The Simple Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 382 Environmental Interference. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 385

Appendix to Chapter 2

Additional Theoretical Notions of Electricity ......................... 388 Additional Facts on Stimulating the Heart. . . . . . . . . . . . . . . . . . . . . . . . . . .. 390

Appendix to Chapter 3 Special Non-Responsive SSI Mode Functions that Control the Escape Rate .................................................. 393

Bradycardia Diagnostic Functions ................................ 393 Rate Smoothing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 393 Dynamic Overdrive ............................................ 394 Sleep Rate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 394

Special Non-Responsive DDD Mode Functions that Control the Escape Rate .................................................. 394

XVIII Contents

Automatic Search of Spontaneous QRS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 397 The Vitatron and Pacesetter Systems (AV Search Hysteresis,

AVD Scanning) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 397 Automatic Switching from AAI to DDD; the ELA System ............. 398

Separate Programming of the Upper P Wave Synchronous Rate and of the Maximal Sensor Rate in DDDR Pacemakers ...................... 399

The Maximal Sensor Rate (MSR) is Programmed Below the Upper P Wave Synchronous Rate (UR) ............................... , 399

The Maximal Sensor Rate Is Programmed at the Upper P Wave Synchronous Rate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 399

The Maximal Sensor Rate Is Programmed Above the Upper P Wave Synchronous Rate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 401

Protection Algorithms Against Atrial Arrhythmias .................... 402 Lower Rate Timing of the Pacemaker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 415

The European Pacemaker Cards and Codes 1998 . . . . . . . . . . . . . . . . . . . . .. 417

Further Reading ................................................. 419

Sources of Figures ............................................... , 421

Some Internet Addresses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 422

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 424

Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 445

Abbreviations 1

A A wave (in atrial electrogram); activa- ERT Elective replacement time tion of the atrium ES Extrasystole

AC Alternating current H Signal of His bundle (His electrogram) Ah Ampere-hour HOCM Hypertrophic obstructive cardiomyo-AH Interval between the atrial electrogram pathy

(A wave) and activation of the His bun- HV Interval between the His bundle (His die (His electrogram) electrogram) and the ventricular elec-

AICD Automatic implantable cardioverterl trogram defibrillator Hz Hertz

AMC Automatic mode conversion IC Integrated circuit AV Atrioventricular ICD Implantable cardioverter/defibrillator AVD AV delay; AV interval ICHD Intersociety Commission for Heart Dis-BBB Bundle branch block ease Resources BOL Begin oflife IEC International Electricotechnical Com-BOS Begin of service mission BPEG British pacing and electrophysiology INR International normalized ratio

group IPG Implantable pulse generator BPM Beats per minute IS-l International standard no. 1

BTS Bradycardia-tachycardia syndrome ISO International Standards Organization CPU Central processing unit I.U. International unit CPX Cardiopulmonary stress testing i.v. Intravenous CSM Carotid sinus massage Jill Kiloohm CSNRT Corrected sinus node recovery time kV Kilovolt CVTL Conditional ventricular tracking limit LAH Left anterior hemiblock CWS Chest wall stimulation LBBB Left bundle-branch block DAB Diagonal atrial bipolar LPH Left posterior hemiblock DC Direct current rnA Milliampere ECG Electrocardiogram min-1 Per minute: unit for rate ELT Endless loop tachycardia ms Millisecond EMI Electromagnetic interference MRI Nuclear magnetic resonance imager EOL End oflife MSNRT Maximal sinus node recovery time EOS End of service MSR Maximal sensor rate EP Evoked potential MSRI Minimal sensor rate interval (according ER Evoked response to MSR) ERI Elective replacement indicator mT Millitesla

1 For abbreviations of the International Pacemaker Code, see foldout table at back of book. ECG uses the signals P - U in accordance with Einthoven; these abbreviations are not listed here. The symbols A, P, V, R are used in the terminology of cardiac pacing to distinguish the following: A atrial stimulus; P atrial spontaneous event; V ventricular stimulus; R ventricular spontaneous event

XX Abbreviations

mV Millivolt PVC Premature ventricular contraction MV Minute ventilation RAM Random access memory

/lA Microampere RBBB Right bundle-branch block

/lJ Microjoule ROM Read only memory

/IT Microtesla RRT Recommended replacement time NASPE North American Society of Pacing SACT Sinoatrial conduction time

and Electrophysiology SNRT Sinus node recovery time NBGcode NASPE/BPEG generic pacemaker SR Sinus rhythm

code SSS Sick sinus syndrome O2 Oxygen SVT Supraventricular tachycardia n Ohm TARP Total atrial refractory period PAC Premature atrial contraction UR Upper rate PMT Pacemaker mediated tachycardia URI Upper rate interval PPM Pulses per minute V Volt PSA Pacer system analyzer VA Ventriculo-atrial PTT Partial thromboplastin time YES Ventricular extrasystole PVARP Postventricular atrial refractory VS-l Voluntary standard NO.1

period WPW Wolff-Parkinson -White syndrome PVB Premature ventricular beat syndrome