Implantation & Equipment Implantation & Equipment Department of Thoracic & Cardiovascular Surgery Seoul National University Hospital.

Slides:



Advertisements
Similar presentations
Appendix E Pacemakers Gail Walraven, Basic Arrhythmias, Seventh Edition ©2011 by Pearson Education, Inc., Upper Saddle River, NJ.
Advertisements

Pacemaker Basics Module 5
Applying Electrical Concepts to Pacemakers Module 4
Dual Chamber Temporary Pacing Operations & Troubleshooting
CARE OF PATIENT ON PACEMAKER. WHAT IS A PACEMAKER? - A cardiac pacemaker is an electronic device that delivers direct stimulation of the heart.
Components of Pacing Leads: Design and Performance Factors.
Circulatory Adaptations to Exercise
Modes of Pacing Seoul National University Hospital
12.4 Guidelines and Format of the Cardiovascular Subsection of CPT The Cardiovascular System subsection: – Heart and Pericardium (33010–33999): Pericardium:
Superconductors A class of materials and compounds whose resistances fall to virtually zero below a certain temperature, T C T C is called the critical.
Pacemakers and Implantable Cardioverter-Defibrillators
How to Handle Lead Problems in Pediatric & Congenital Heart Disease
Exam Two Material Chapters 18 & 19. Heart Anatomy Approximately the _ Location – In the mediastinum between _ – On the superior surface of diaphragm –
Myocardial Ischemia, Injury, and Infarction
Pacemaker Therapy and the Conducting System of the Heart By: Tom Kerrigan.
Pacemaker & its Classification
Pacemaker Follow-up Alpay Çeliker MD. Hacettepe University Department of Pediatric Cardiology 3rd International Summer School on Cardiac Arrhythmias, 9-12.
Single Chamber Temporary Pacing Operations & Troubleshooting.
A Case of Dizziness A 68 year old female arrives at the emergency room in an ambulance. That evening she had been feeling “weak and dizzy” after ingesting.
Cardiac Cycle and Conduction System of the Heart.
Diagnostic Techniques Michael Del Core, M.D.. History Skills  History Symptoms. You need to ascertain when the problem started, what if anything brought.
Basic Concepts—Electricity and Pacemakers Module 3
Electrical Properties
The Cardiovascular System
Cardiovascular System
Functions of the Heart Generating blood pressure Routing blood
The Cardiovascular System
Lecture 8 Electrical energy EMF Resistors in series and parallel
Normal electrocardiogram
Alpay Celiker M.D. Acıbadem University.  Advances in lead and device technology allow pacemaker system implantation in children and even in neonates.
Exercise 27 Gross Anatomy of the Heart BI 232. Mediastinum  The heart and pericardial cavity are located within the mediastinum, a centrally located.
CARDIOVASCULAR SYSTEM Heart Physiology. CARDIAC CYCLE Systole *Atria Contract, Ventricles Fill *Ventricles Contract, Blood Forced into Aorta and Pulmonary.
Human Anatomy, 3rd edition Prentice Hall, © 2001 The Heart Chapter 21.
BIOL 2030 Human Anatomy & Physiology II What is the function of the heart? the heart’s function is to… Pump characteristics: Essentially ______________,
The Heart Unit 11. The heart is the pump that keeps blood moving around a closed circuit of blood vessels. It beats over 100,000 times a day. Introduction.
Safety of Lead Extraction After Decades of Implantation Alpay Çeliker M.D. Acıbadem University, Istanbul.
The Hearts Electrical Activity
Pacemakers.
Copyright © 2006 Thomson Delmar Learning Chapter 8 Have a Heart The Cardiovascular System.
Cardiovascular System. Functions of Cardiovascular System 1. generate blood pressure 2. send oxygenated blood to organs 3. insure one-way blood flow 4.
Cardiovascular System Integrates the body as a unit and provides the muscles a continuous stream of Nutrients and Oxygen AND Rapid Removal of By-products.
ADVANCED BIOLOGY Heart. SIZE, SHAPE, LOCATION Fist Hollow, cone shaped Mediastinum, Rests on diaphragm, posterior to sternum, Lungs on each side.
 2/3 of the mass lies to the left of the body’s midline  The apex lies on the diaphragm.
Pacemakers and AICD ’ s. Pacemaker Basics Provides electrical stimuli to cause cardiac contraction when intrinsic cardiac activity is inappropriately.
Advanced Biology Heart. Size, Shape, Location Fist Fist Hollow, cone shaped Hollow, cone shaped Mediastinum, Rests on diaphragm, posterior to sternum,
Chapter 11 - The Cardiovascular System: The Heart $100 $200 $300 $400 $500 $100$100$100 $200 $300 $400 $500 Heart Anatomy Pathway of Blood Heart Conduction.
DR—Noha Elsayed The Circulatory System.
Supparerk Prichayudh M.D
Cardiovascular Therapeutic Management 2013
Heart Pt. II.
The Cardiovascular System Chapter Components 1. There are two components to the system: the heart and the blood vessels. 2. The heart pumps the.
Date of download: 6/25/2016 Copyright © The American College of Cardiology. All rights reserved. From: Mechanism, localization and cure of atrial arrhythmias.
CRT Overview This lecture is intended to give a basic overview of HF to include: -General knowledge of the cardiac cycle and how a normal heart should.
Basics of Pacemaker Functioning
Cardiology for Dr. Pelaez By Sai Kumar Reddy American International Medical University, St.Lucia.
Objectives Identify the components of pacing systems and their respective functions Define basic electrical terminology Describe the relationship of amplitude.
CARDIAC PACEMAKER Ms. Saranya N 27-Feb-18 Cardiac Pacemaker.
Questions included for Critical Care Competency Day
Temporary Pacemakers.
Pacemaker II Lecture (6).
Therapeutic equipment I
The Cardiovascular System
PACEMAKER Yoga Yuniadi
The Circulatory System
CARDIAC PACING NUR 422.
Pacemakers.
Clinical Intracardiac Electrophysiologic Testing: Technique, Diagnostic Indications, and Therapeutic Uses  STEPHEN C. HAMMILL, M.D.  Mayo Clinic Proceedings 
EKGs and Pacemakers Cooper University Hospital
Presentation transcript:

Implantation & Equipment Implantation & Equipment Department of Thoracic & Cardiovascular Surgery Seoul National University Hospital

Types of Pacemaker Temporary Pacemaker Permanent Pacemaker

The Pacemaker System Patient Lead Pacemaker Programmer Lead Pacemaker

Pacing System Analysis Ohm’s law ; R=E/I R; resistance in ohms E; potential in volts I ; current in amps Unipolar system: the negative alligator clip of the cable is attached to the electrode(anode) and the positive clip to an indifferent electrode(12-15cm2, stainless steel) Bipolar system: the cathode(tip electrode) is usually the most proximal(pin) terminal and anode(ring electrode) is connected to the less proximal(ring) terminal of the lead

Pacing Threshold & Sensitivity Current threshold(mA) is the quantity of electron/ion flow across the electrode that is required to initiate depolarization of the myocardium. This may also be expressed in terms of current density or current per unit of electrode surface area, usually milliamps per square millimeter The voltage threshold(V) is the amount of potential drop required to maintain this current flow Lead impedance is a measure of the total resistance to current flow along the lead conductors, across the electrode-tissue interface, and across the body tissues

Pacing Threshold & Impedance Pulse generator and lead along the body provide a continuous circuit for current flow and the total pacing system resistance is comprised of three part Lead conductor and tissue resistance are relatively constant, while polarization resistance increases throughout the period during which current is flowing Largely as a result of polarization resistance, lead impedance varies directly with pulse duration and current amplitude and inversely with electrode surface area

Stimulation Threshold & Resistance With time, a layer of fibrosis forms around the electrode tip, causing separation of the electrode surface and viable tissue The stimulation threshold at implant will provide a basis for estimating the expected rise in thresholds that results from this fibrotic buildup Threshold may rise transiently to levels of 4 to 5 times those at implant but generally decline after days to levels of 2 or 3 times the acute values Newer electrode materials and configuration may lessen the development of the fibrous capsule, thus decreasing both transient & permanent rises in threshold

Pacing Threshold & Impedance Pulse generator and lead along the body provide a continuous circuit for current flow and the total pacing system resistance is comprised of three part Lead conductor and tissue resistance are relatively constant, while polarization resistance increases throughout the period during which current is flowing Largely as a result of polarization resistance, lead impedance varies directly with pulse duration and current amplitude and inversely with electrode surface area

Pacing System Resistance Lead conductor elements ohms Body tissues ohms Polarization resistance 15-35% ( The alignment of oppositely charged ions at the electrode-tissue interface during a pacing impulse)

Acceptable Threshold Limit (Acute) Acute implant stimulation threshold –Atrium Less than Volts Less than mA(current) –Ventricular Less than 1.0 Volts Less than 2.0mA(current) Acute implant sensing thresholds –Atrium Greater than mV –Ventricular Greater than 5.0 mV Acute implant lead impedance. Both chamber within ohms

Acceptable Threshold Limit (Chronic) Chronic voltage stimulation threshold Less than 50% of nominal voltage output of pulse generator at pulse width <1.0 Chronic current stimulation threshold –Atrium ; less than mA –Ventricular; less than mA Chronic sensing thresholds –Atrium ; greater than 1.0 mV –Ventricular ; greater than 4.0 mV Chronic lead impedance –Atrium ; ohms –Ventricular ; ohms

Acute Threshold Measurement  Factors Type of lead Lead-tissue interface Location of lead within the heart Length of time after lead fixation

Optimal Placement of Leads Acceptable eletrophysiologic values Visual assessment on fluoroscopic examination Adequate securing of the lead and is in good contact with viable tissue

Electrophysiologic Complications Pacemaker syndrome Ventricle Atrial Pacemaker-mediated tachycardia

Venous Route Subclavian vein Cephalic vein External jugular V Internal jugular V Transvenous Implantation

Atrial Endocardial Placement

Ventricle Atrial

Epicardial Implantation  Indications Multiple endocardial lead failure Abnormalities of thoracic venous anatomy Presence of congenital heart disease Presence of tricuspid valve prosthesis Repeated development of exit block of endocardial lead Small infants and occasionally in children

Epicardial Implantation A; Subxiphoid approach B; Anterior thoracotomy Ideal electrode distance in bipolar pacing; cm

Connection of the leads to the Pacing System Analyzer (PSA)

Connection to Pacemaker Insure the leads are placed behind the Pacemaker

Temporary Epicardial Pacing Temporary pacing leads are invaluable in the diagnosis and treatment of arrhythmia after cardiac surgery. Bipolar leads have been shown to have better pacing and sensing function compared with unipolar leads Atrial leads were implanted directly into the lateral muscular part of right atrium near interatrial groove. Temporary epicardial atrial leads are more effective when placed in the atrial body of right atrium than wrapped within the right atrial appendage Ventricular leads were implanted into the myocardium on the anterior surface of the right ventricle.

Biventricular Pacing  Indication Adjuvant treatment for patients with heart failure and intraventricular conduction delay Acute hemodynamic improvement is most likely to be observed when QRS duration is greater than 150 ms in patients with left bundle-branch block.  Techniques Usually, left ventricular lead implant is accomplished percutaneously through coronary sinus cannulation, advancing the lead into a major cardiac vein. Epicardial lead placement is often a rescue procedure, so it offers advantages related to its safety and shorter implant time.

Biventricular Epicardial Pacing  Selection of implantation site Selection of the best implantation site was made by echocardiography with tissue Doppler imaging in combination with intraoperative electrophysiologic measurements. Leads were positioned, but not fixed, on several spots of the left ventricular epicardial surface. The final site was chosen on the basis of the longest atrioventricular delay in activation. The target was the posterolateral wall of the left ventricle in most of the patients

Early Implantation Complications 1. Surgical Pneumothorax Arterial or venous vascular injury Air embolism Cardiac chamber perforation Lead dislodgment due to inadequate fixation Neural (brachial plexus) injury 2. Wound Hematoma Infection Drainage

Late Implantation Complications Surgical 1. Venous thrombosis 2. Pulmonary embolism 3. Constrictive pericarditis ( after asymptomatic perforation) 4. Pulmonary embolism 5. Tricuspid valvular insufficiency Wound 1. Infection 2. Generator migration 3. Skin erosion 4. Device manipulation by patient (Twiddler’s syndrome)

Pacemaker Malfunction (Pacing) 1. Lead position Displacement Microdislodgment Perforation Poor placement at implantation 2. Inadequate device output Power source failure (end of life) Programming error below safety factor Microchip component failure 3. Increased pacing threshold Acute postimplant rise Late fibrotic exit block Myocardial infarction Metabolic, toxic, or electrical influence 4. High resistance in lead system Lead fracture

Pacemaker Malfunction (Sensing) 1. Skeletal myopotentials Pectoral Abdominal Diaphragmatic 2. Cardiac events T-wave Atrial R-wave sensing Ventricular P-wave sensing Concealed extrasystoles 3. Generator malfunction Programming error-high sensitivity or output Programming error-short refractory period Microchip malfunction 4. Connector malfunction Loose set screw Current leak from header 5. Lead malfunction Conductor fracture Insulation break Polarization potentials 6. Environmental interference Electromagnetic

Transvenous Lead Extraction A.Cook transvenous lead extraction system B. Common sites of adhesion