Basics of Pacing

Ruth Hickling, RN-BSN

Tasha Conley, RN-BSN
The Cardiac
Conduction
System
Cardiac Conduction System Review
Normal Conduction
Conduction QRS
QRS
Complex
Complex

RR

ST
PR ST
PP
PR
segment
segment
segment
segment TT

ST interval
ST interval

PR Interval
Q
Q
PR Interval
SS
QT Interval
QT Interval
 Indications for Pacing
Documented evidence of Arrhythmia and Symptoms
• Symptomatic Bradycardia
• Sick Sinus Syndrome (AKA tachy/brady)
• Sinus Arrest or Sinoatrial (SA) Exit Block
• Atrial Fibrillation with slow V response or
s/p AVNA for AF with RVR
• Atrioventricular Block
• First Degree (symptomatic)
• Second Degree, Mobitz I and II
• Third Degree or Complete Heart Block
• Carotid Sinus Hypersensitivity/Syncope
Possible Symptoms

 Syncope
Dizziness
Confusion
Fatigue
Shortness of Breath
Limited Exercise Tolerance
 Keeping it Simple

If the Sinus Node

Doesn’t Fire…

… then we need
to pace the atrium
 Keeping it Simple

If the AV node
does not
appropriately
conduct…

...then we need to
pace the ventricle
 In a ‘Nut Shell’
Pacemakers
1. Keep the heart from going too slow

2. Provide AV Synchrony

3. Aid in Chronotropic response

 Indications for ICD Implantation
Primary Prevention Secondary Prevention
• Congenital Heart • Prior Cardiac Arrest
Disease • Ventricular
• Long QT Syndrome Tachycardia
• Cardiomyopathy that • Ventricular
meets appropriate Fibrillation
NYHE guidelines
Ischemic
Non-Ischemic
Idiopathic
Hypertrophic
What makes up a
Pacemaker / AICD
System?
 Basic Components of
Pacing/AICD System
• Pulse Generator Pacemaker
• Battery
• Circuitry
• Case
• Header
• Lead(s)
• Systems can have up to
three leads depending on
implant indication
 Components of a pacemaker pulse
generator. Also called “the Can”

“Brain”
Single-Chamber
System
• The pacing lead is
implanted in the atrium
or ventricle, depending
on the chamber to be
paced and sensed
Dual Chamber
Systems
Have Two Leads
• One in the atrium
• One in the ventricle
Biventricular
Pacing Systems
Also called Cardiac Resynchronization
Therapy (CRT) pacemakers have

 a Right ventricular lead and a left

ventricular lead.
 These leads force the ventricles
to contract at the same time for
“resynchronization”

 May not have atrial lead with

history of chronic atrial fibrillation
Implantable Cardiac
Device Function and
Programming
 Sensing
What the device “sees”
• Monitor the hearts intrinsic electrical activity

Think of a fence…
“Can’t see the hearts activity?!?”, “Sees too much!” “Ahhh, Just Right!”
(Undersensing) (Oversensing) (Appropriate sensing)

EMI, Myopotential
 Pacing
The delivery of an electrical impulse to elicit contraction
of the heart muscle.

CAPTURE THRESHOLD – minimum amount of energy

needed to elicit contraction of the heart.

• Amplitude – How much energy (measured in Voltage)

• Pulse Width – Over what time period (measured in ms)

Voltages are set to 2 times the

amplitude of capture threshold to
ensure safety
 Pacing Parameters
Lower Rate Limit (LRL):
Nominal - 60bpm
Rest rate – 50bpm
Pts with AF s/p AVNA 80bpm for 6 weeks
PVCs

Upper Rate Limit (URL): How fast device will pace

Patient can have OWN intrinsic rates higher that
programmed URL
 Sensors – Rate Response
(Not to be confused with “sensing”)

Provide appropriate increase in heart rate with

activity for the those patients who have chronotropic
incompetence
“Accelerometer”
• Spring board system
• Measures heal strike

“Physiologic”
• Only available in pacemakers
• CLS (closed loop system)
• Minute Ventilation – not
appropriate for patient’s on a
ventilator
 Magnet Response
Pacemakers ICDs

• “Shuts the eyes of the • Temporarily deactivates

pacemaker” (Sensing) ICD therapies

• Force A/V pacing at a

specific rate, which is
dependent on the pacemaker
manufacturer
(Ranging between 85-100bpm)
 Basic Differences between
Pacemakers and Defibrillators

Pacemakers Defibrillators
 All have pacemaker
 Maintain HR, CO and component, but may not be
AV synchrony utilized if no pacing
indication
 Pace at a specified rate
when magnet is applied  Treat sustained VT/VF with
pacing (ATP) and or shocks
 Are not defibrillators
 Magnet application suspends
 They do not stop fast detection for VT/VF and
heart rates prevents treatment. It does
not affect Pacing rates.
 Keeping it Simple

• ICDs are intended to treat potentially

life threatening arrhythmias.
• ICDs can function as a Pacemaker
when pacing is indicated.
 NBG Code
NASPE/BPEG Generic

I II III IV V

Chamber(s) Chamber(s) Mode(s) of Programmable Antitachycardia

Paced Sensed Response Functions Functions

A = Atrium A = Atrium T = Triggered R = Rate P = Paced

Modulated
V = Ventricle V = Ventricle I = Inhibited C= S = Shocks
Communicating
D = Dual D = Dual D = Dual M= D = Dual
(A&V) (A&V) Multiprogrammable (P&S)
O= None O = None O = None P = Simple O = None
Programmable
O = None
 Common Pacing Modes
Single Chamber Dual Chamber
• VVI • DDD
• VVIR • DDDR
• AAI • DDI
• AAIR • DDIR
 VVIR

V: ventricle is paced

V: ventricle is sensed

I: pacing is inhibited in response to a sensed event

R: rate responsive
This is a ventricular demand mode with artificial rate
response
 D D DR
D: both chambers are paced

D: both chambers are sensed

D: pacemaker will either inhibit or trigger in

response to a sensed event

R: rate responsive
This is a dual chamber “universal” mode with
artificial rate response
 Four Faces of DDD Pacing
Atrial pace - Ventricular pace

Atrial pace - Ventricular sense

Atrial sense - Ventricular sense

Atrial sense - Ventricular pace

 DDD Pacing Example

Atrial Pace – Ventricular Pace

 DDD Pacing Example

Atrial sense - Ventricular pace

“Atrial tracking”
 DDD Pacing Example

Atrial Pace – Ventricular Sense

 Could this be normal DDD
Pacemaker Function?

Normal sinus rhythm with no pacing

YES!
 What About This?

Atrial Flutter with Variable V rate

Absolutely!
 Identifying
Pacemaker/ICD
Related Issues
 What do you see?

Loss ofOf
Loss Capture
Capture
Capture
 What do you see?
Loss Of
Capture Undersensed
QRS

Undersensing
More Undersensing

undersensing
Typical Paced Beat
Normal and Psuedofusion look the same
Pseudofusion
Fusion beats can have several
different looks
 Helpful steps to take when calling
for trouble shooting assistance
• Make sure the telemetry monitor is not undersensing
beats such as a PVC.

• Make sure the “pacing spikes” are not artifact

• Please save copies or telemetry strips for questionable

rhythms.
• Often we can determine if device functionality is
an issue just by looking at these.

• Whenever possible, make sure to save 2 ECG

channels.
New Advancements in the
World of Cardiac Devices
Implantable Loop
Recorders
Implantable Loop Recorder
A Smaller version
The Evolution of Pacemakers
Then Now
Leadless Pacemakers
Progression of ICDs
Subcutaneous ICD
It is always a good idea to have device settings
posted above the head of the bed.
• Device settings can be obtained from the cardiac rounding
nurse

• Signs for posting should be located at central stations on

your unit

• Essential information
 lower and upper rate limits for pacing
 Intervention rates for VT and VF
 Need Help? Questions or Concerns?

Page the Pacemaker Nurse

(734) 670-1825
Available M-F 8am to 5pm

After hours page appropriate

company representative P
Questions?!?
 References
Biotronik (n.d.). Closed Loop Stimulation (CLS). Retrieved February 16, 2015 from
http://www.biotronik.com/wps/wcm/connect/en_us_web/biotronik/sub_top/
healthcareprofessionals/products/bradycardiatherapy?p=http://www.biotr
onik.com/wps/wcm/connect/en_us_web/biotronik/sub_top/healthcareprofes
sionals/products/bradycardiatherapy/closed_loop_stimulation/page_closed
_loop_stimulation&pw=974&pt=

Boston Scientific. (2011). Restoring Appropriate Rate for Chronotropic Incompetence. Retrieved February 16,
2015 from http://www.chronotropic- incompetence.eu/en/treatment-of-chronotropic-incompetence

Kutalek, S., Sharma, A., McWilliams, M., Wilkoff, B., Leonen, A., Hallstrom, A., & Kudenchuk, P. (2008).
Effect of pacing for soft indications on mortality and heart failure in the dual chamber and VVI
implantable defibrillator (DAVID) trial. Pacing & Clinical Electrophysiology, 31(7), 828-837

Medtronic, (2013). Clinical gudelines and inidcations. Retrieved February 16, 2015 from
http://www.medtronic.com/for-healthcare-professionals/products-therapies/cardiac-
rhythm/therapies/tachyarrhythmia-management/clincial-guidelines-indications/

The NBG Code, (n.d.). The NBG Code: NASPE?BEPG generic. Retrieved February 16, 2015 from
http://www.pacemaker.vuurwerk.nl/info/nbg_code__naspe.htm