1. Arrhythmias/Pacemakers trouble shooting
Magdi Sami, MD, FRCP(C), FACC
Professor of Medicine, MCGILL Univ.
Senior Cardiologist, MUHC

2. Disclosures
No conflicts to report for this talk

3. Learning objectives Complex ECG’s arrhythmia analysis
Basic troubleshooting of pacemaker malfunctions.

4. PVC ou PAC & abberance?

12. What is the heart rate?What is the rhythm?
The Alan E. Lindsay ECG Learning Center ;
33 x 6 = 198 bpm

13. What is the rate? The rhythm?
The Alan E. Lindsay ECG Learning Center ;
Short R deep S in V5, V6 pathognomonic of VT

14. 52 Y old hypertensive presented with palpitations after jogging

15.      
                   
This is a recording from an 80 year old man. He was taking Hytrin, Metoprolol, Adalat, Dyazide and ASA.
QT (ms)
559
QRS axis (degrees) 80
                                                                                                        

17. Pacemaker trouble shoot Outline
Pacemaker codes
Pacemaker configuration
Examples

18. Pacemaker Codes Position Function 1 Chambers Paced 2 Chambers Sensed 3
Response to Sensed Stimulus 4
Rate Modulation?
O (none) O
O (non-rate responsive)
A (atrium) A
T (triggered)
R (rate responsive)
V (ventricle) V
I (inhibited)
D (both atrium & ventricle)

19. Pacemaker Configurations VOO
Indications
Temporary mode some-times used during surgery to prevent interference from electrocautery

20. Pacemaker Configurations AAI
Indications
Sick sinus syndrome in the absence of AV node disease or atrial fibrillation.

21. Pacemaker Configurations DDD
Indications
1. The combination of AV block and SSS.
2. Patients with LV dysfunction and LV hypertrophy who need coordination of atrial and ventricular contractions to maintain adequate CO.

22. Problem with Pacemaker?
Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.
Causes:
Threshold rise (electrolytes, drugs)
Lead dislodgement
Lead fracture
RV infarct

23. Problem with Pacemaker?
Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.
Causes:
Oversensing
Battery failure
Internal insulation failure
Conductor coil fracture

24. Problem with Pacemaker?
Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.
Causes:
Crosstalk

25. Problems with Pacemakers
Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 7th ed., 2005.
Causes:
Undersensing
Lead Fracture

26. Is this pacemaker capturing?
The Alan E. Lindsay ECG Learning Center ;
Atrial sensed, ventricular paced
Consistent with DDD or VDD

27. What’s wrong? Failure to Pace
The Alan E. Lindsay ECG Learning Center ;
Failure to Pace

28. Ce patient as-t’il besoin d,un pacemaker?

29. Where is the block?

30. Second Degree A-V Block (Mobitz I or Wenckebach)

31. Where is the Block?

32. Mobitz Type II

34. Third Degree A-V Bloc

35. ANY QUESTIONS?