Pacemaker follow up and troubleshooting This is one in a series of lecturers to complete the subject but to be practical we must start with this, in the past we hade only one (temporary )pulse generator now we have five and some times all of them are in-use.

When the patient leaves the cath When the patient leaves the cath. lab with a permanent pacemaker what should I do? A picture of Einstein deeply thinking, some one admits the patient, some one implant the temp pacer, some one implant the perminant , then me the patient and the pacemaker are left togather.

Should I? A- Educate the patient . B- Document. C- Start follow up. D- Non of the above. E- All of the above.

Educate The patient activity Wound care Concerns Follow up The arm on the same side as the pacemaker should not be lifted above shoulder level for four weeks. He should be careful not to hit or rub the insertion site. Instruct the patient not to "fiddle" or play with the pacemaker under your skin. avoid activities like heavy lifting, running, or contact sports. Do not lift more than 5 kilograms for two weeks. If you have any specific questions regarding activity, ask your doctor. It is best to take it easy for four weeks at home to avoid damaging the pacemaker. Cellular Phones: You may use a cellular phone; however, do not hold the cellular phone on the same side as your pacemaker or place it in your shirt pocket over the pacemaker. Strong Magnets: Avoid strong magnets. Examples are magnets used for an MRI and hand-held security wands. Strong Electrical Fields: Avoid strong electrical fields. Examples are radio transmitting towers, ham radios, and arc welders. Also, avoid leaning over the open hood of a running car because its electrical field can interfere with your pacemaker. Microwave Ovens: You may cook with a microwave oven. Microwave ovens in good working order are safe to use. The pacemaker site should be kept clean and dry. The patient may take a tub bath when you go home after getting a pacemaker, but keep the incision dry for at least two weeks. The dressing should be changed every day using sterile gauze. He must not use ointment on the incision site unless instructed to do so by the doctor. Carefully inspect the incision with each dressing change to note any redness, swelling or discharge. Wound care Emphasize on the importance of follow up Give him the exact place and time Provide him with a phone number activity Concerns Follow up

Document • Demographic information on patient Pacemaker operative record Manufacturer, model number and serial number of all implanted hardware Records of data from each follow-up visit • Patient symptoms or complaints Demographic information on patient (name, age, telephone number or other means of contract, next of kin or alternative way of contacting a patient) Oprative records (what was changed and whats happened) Records of data from each follow-up visit including programmed setting, telemetry threshold evaluations and rhythm strips Evaluation of the pacemaker site Documentation of hardware advisory or recall, or any surgical complications Current medications

What is the aim of the follow up visits? 1- patient and family education. 2- Collect and maintain patient records and institutional databases. 3- Optimize pacing system function including maximizing power source utilization. 4- detect and correct pacemaker system abnormalities. 5- Act as a resource centre for cardiac pacing (RESERCH AND TRAINING)

Frequency Of Pacemaker Follow Up Postimplantation Two weeks 12 weeks Six months End of life paramiters and elective replacment indicators Intensified follow up period Maintenance period

Considerations in determining a pacemaker follow-up schedule • Known reliability of the implanted pacing system. • How long the patient has had the pacemaker • Programmed parameters (higher outputs = shorter time from elective replacement time to end of service) • Complexity of pacing system. • Collection duration for diagnostics. • Concurrent use of implantable cardioverter-defibrillator. • Application of cardioversion, electrocautery or defibrillation. • Patient dependency on pacing. • Stability of rhythm and cardiovascular symptoms. • High or unstable thresholds or low and stable thresholds. • Patient’s ability to report symptoms accurately. • Patient distance from follow-up clinic. Considerations in determining a pacemaker follow-up schedule Patient-related considerations Pacer system-related considerations

Troubleshooting صورة واحد ببندقية

Patient related problems What troubles to shoot? Patient related problems 1- pocket related problems. 2- pacemaker syndrome. 3- accessory muscle stimulation.

Pacemaker syndrome Pocket and muscle stimulatin(perforatin, insulatin breake,flipping and unipolar)

Patient related problems Under passing or no pacing What troubles to shoot? Patient related problems Under passing or no pacing Oversensing can produce underpassing Farfeald sensing, myopotential, interferance, crosstalk

Electrode tissue interface: 1- lead imaturity. 2- electrolytes. 3- drugs. 4- MI. Over sensing: 1-myopotential. 2- interference. 3-cross-talke. 4- fare field sensing. Improper fixation. Generator failure: 1- temporary. 2- perminant. Lead problems: 1- twiddelers syndrome. 2- lead fructure. 3- insulation breake Battery depletion

Increased Current Drain Pacing and sensing problems Current is escaping Decreased Resistance Increased Current Drain Pacing and sensing problems

Decreased Current Drain Pacing and sensing problems Current cannot reach heart Increased Resistance Decreased Current Drain Pacing and sensing problems

Acufix

The ability of a device to sense intrinsic signals Think of sensitivity as a wall. Raise the wall and you can see less. Lower the wall and you see more.

1.0 mV 4.0 mV 2.0 mV

Pacing system senses signals other than Myopotential Oversensing T - Wave Pacing system senses signals other than P/R waves and inhibits pacing output.

1.0 mV 4.0 mV 2.0 mV

Patient related problems Under passing or no pacing What troubles to shoot? Patient related problems Under passing or no pacing Over passing

1- Endless loop tachycardia. 2- Atrial arrhythmia or myopotential Under sensing: 1-Lead problem 2- Electrode tissue interface. Interference: MRI.

To correct: Programming a lower number increases the sensitivity of the device, causing more signals to be sensed. 1.0 mV 4.0 mV 2.0 mV

Patient related problems Under passing or no pacing What troubles to shoot? Patient related problems Under passing or no pacing Over passing Psudo-malfunction 1- hysteresis., 2- rate smoothing. 3- mood swithc. 4- fusion and psudo-fusion.

Escape Interval = Pacing interval

Rate Hysteresis with Rate Smoothing 45 50 55 60 65 70 A B C Hysteresis Rate LRL Rate (ppm) A - Pacing inhibited by intrinsic rate > LRL B - Intrinsic rate falls below the Hysteresis Offset, pacing rate jumps to LRL C - DDD pacing at the LRL

An intrinsic cardiac depolarization occurs Fusion Beats: CHANGE in MORPHOLOGY An intrinsic cardiac depolarization occurs simultaneously with the pacemaker output pulse. Fusion

The pacemaker paces immediately after, or in an intrinsic depolarization. Pseudofusion