Post on 18-Feb-2017
PACEMAKER ECGs
Presented By:Yasmeen Kamal
Tanta Rhythm Group (TRG)
A gentleman who had a pacemaker implanted 3 years ago came to your clinic to check on his device.
Unfortunately he forgot his card So…. HOW will you deal with him ?
A 12 Lead ECG is made , what can you see ?
In order to reach a proper diagnosis , you should fulfill the following points
1. Mode of Pacing2. Rate3. Capture function4. Sensing function5. What is the underlying
rhythm?6. What to do next?
No atrial spikes, each spike is followed by ventricular activity so It is Ventricular pacing.HR =80 bpm , no intrinsic ventricular beats , underlying rhythm is AF.
What to do next?
1-sensing function should be assessed by using the specific programmer
2-CHADsVaSc score is calculated to assess the need of OAC
North American Society of Pacing and Electrophysiology/British Pacing and Electrophysiology Group
Modes of pacing
Another Example of paced ECG
Mode :Here , We can see 2 spikes.One preceding the p wave and the other is preceding the R wave and pacing is sequentialSo it is a Dual Chamber Pacemaker.
Rate:By Using Calibers from one atrial spike to the next one.
Capture:Each atrial spike is followed by atrial depolarization and each ventricular spike is followed by Vent. dep.
Sensing Function :Couldn’t be assessed .. 100 % pacing
The underlying Rhythm :It is probably Bi-nodal disease
What to do next?Check the sensing function using the programmerBy lowering both atrial and ventricular rates
So what about this strip?
What about it!!
There are pacemaker spikes followed by atrial activity. There is association between each paced atrial activity and Intrinsic ventricular activityMode is : AAI / DDD
Rate : AP-AP
Capture function of the atrium is appropriate
Sensing function : Atrial sensing couldn’t be assessed
Underlying Rhythm : SA nodal disease
What to do next? Check the mode of pacingIf DDD you should test ventricular captureAnd atrial sensing should be assessed in either modes
DDDAS – VPCapture : ventricular capture is appropriatesensing : Atrial sensing function is appropriateUnderlying rhythm : AV nodal diseaseWhat to do next? Check ventricular sensing by prolonging AV delay
Explain those beats
Capture beat: an intrinsic beat that captures the ventricle
Fusion: a combination between intrinsic and paced events
Pseudofusion: occurs when a spike falls on an intrinsic beat
Paced beatFused beatIntrinsic
“capture” beatPseudo fusion
Mode : DDDCapture :Appropriate in both chambersSensing Function : ok regarding both chambers
Explain this?
Hysteresis Function
Is their Anything wrong?
Take a Quick LOOK at V1
PaceMaker Malfunction
This strip was seen in a Holter Monitoring of a patient who had a VVIR pacemaker and was recently Complaining of
dizziness while playing Basket ball?
Oversensing of myopotentials of pectoralis major muscleOversensing Leads to Underpacing
The pacemaker fails to generate an impulse
What is called “Failure of output”
Ventricular Oversensing
Undersensing
Failure of Capture
Spikes not followed by ventricular eventsPseudo fusion beats “3rd and 5th from lt”
Pacemaker mediated Tachycardia
PMT Initiated by atrial non capture
A strip is taken from a Patient with VVI pacemaker while interrogating the device
Explain?
Magnet Mode Behavior acting temporarily like VOO
Automatic Mode Switching
Any Questions?
Thank You