Cardiac Pacing and Implantable

Cardioverter defibrillator

Peter Peetsma
Head Division of Nursing
Cardiac Center Cinere-Depok
Indonesia
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Normal conduction system of the heart

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Stimulation impulses of a diseased heart tissue may be:

• Intermittent.
SA node
• Too slow or too fast
• Irregular LBB

• Not generated at all

• At an inappropriate rate AV node

RBB

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 Definition of a pacemaker

An electric device that delivers direct

electrical stimulation to stimulate the
myocardium to depolarize , initiating
a mechanical contraction.

Device = Pulse generator : Battery + electrical circuit

Electrical stimulation = Pacing

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 Pacemakers

Defibrillator Mindray
with transcutaneous pacemaker function

Permanent pacemakers
Temporary pacemakers

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 Leads Are Insulated Wires That:

• Deliver electrical
impulses from the
pulse generator to
the heart Lead

• Sense cardiac
depolarization

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 Lead Characterization
• Position within the heart • Polarity
– Endocardial or transvenous leads
– Unipolar
– Epicardial leads
– Bipolar

• Fixation mechanism
– Active/Screw-in
– Passive/Tined
• Insulator
– Silicone
• Shape
– Straight – Polyurethane
– J-shaped used in the atrium

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 Main function of a pacemaker

• Pacing = To give electrical impulses to the heart if if there

is no natural electrical activity
Measured in milli-ampere (mA) = the power of the impulse

• Sensing = Monitoring the natural electrical activity of the

heart and not give electrical impulses from the
Pulse generator
Measured in millivolt (mV) = the level of monitoring

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Electrical stimulation of the pulse generator
can be seen as a spike
A spike is a perfectly vertical line , need to be followed by a P wave if the
atrium is paced; or by an R wave if the ventricle is paced. (Capture)
Spikes Capture

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Atrial and ventricular pacing rhytm
Atrial capture Ventricle capture

Atrial spike Ventricle spike

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 Capture and no capture.
Spike followed by capture

Spike not followed by capture

Capture :The ability of myocardium to contract when stimulated by electrical impulse

No capture: The electrical impulse is not strong enough to stimulate a contraction of myocardium

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Atrial and ventricular pacing rhytm

12 channel ECG with atrial and ventricular spikes

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 Good sensing

Sensing
1,5 mV

Good sensing of the natural electrical activity of the heart.

The pacemaker measure the R-waves and will not give an
electrical impulse.

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 Under sensing

Under sensing
2,5 mV

The pacemaker will not measure the R-waves and will give an electrical
impulse throughout the normal activity of the heart

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 Over sensing

Over sensing
O,5 mV

The pacemaker monitors also the P-waves and the T-waves or other
electric signals and will interpretate this as R- waves, even when the
R-waves will fall out.

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 Pacemaker codes

The North American Society of Pacing and Electrophysiology and the

British Pacing and Electrophysiology Group have developed a code to
describe various pacing modes s

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 Temporary Transcutaneous Pacemaker
• Transcutaneous pacing (also called external pacing) is temporary
therapy of pacing a patient's heart during a medical emergency in
patients with bradycardia with symptoms of shock. It is accomplished
by delivering pulses of electric current through the patient's chest,
which stimulates the heart to contract

• Pacing Pads are placed on the patient's chest, either in the

anterior/lateral position or the anterior/posterior position .The pads are
with cable are attached with a defibrillator with pacing function.

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 Temporary Transcutaneous Pacemaker

• Pacing in this emergency situation can be very uncomfortable for

the patient and sedation should be considered.
• Is very helpfull in emergency.
• Is not comfortable for the patient ( pain, skin burns)
• Sedation should be considered.

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Temporary Transcutaneous Pacemaker

The Mindray defibrillator has the possibility for transcutaneous pacing

Pacing pads with cable for transcutaneous pacing

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Temporary Transcutaneous Pacemaker

The anterior–posterior position is preferred. It minimize the

electrical impedance

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 Temporary transvenous pacemaker.

• Transvenous cardiac pacing ( also called endocardial pacing) is a life saving

intervention or elective in procedures which may promote bradycardia to correct
slow heartrhytm that do not respons to drug therapy. A pacemaker lead is
inserted into the right atrium or the right ventricle or both.

• It is used when the therapy is needed temporary or when a permanent

pacemaker is either not necessary or not immediate available

• Transvenous cardiac pacing, also called endocardial pacing, is a potentially life saving intervention used
primarily to correct profound bradycardia. It can be used to treat symptomatic bradycardias that do not respond to
transcutaneous pacing or to drug therapy. Transvenous pacing is achieved by threading a pacing electrode
through a vein into the right atrium, right ventricle, or both

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 Temporary transvenous pacemaker.
The veins that commonly are used:

– Femoral vein
– Subclavian vein
– Jugular ( external or internal) vein

Pulse generator with

consumables necessary for
insertion procedure
Example of temporary pulse generator with cable

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Setting of temporary pacemaker

As an example the Medtronic model 5388 is used .

(All types use the same settings)

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 Complications of using a temporary
transvenous pacemaker

• Failure to secure venous acces

• Failure to place the lead correctly in atrium or ventricle
• Infection
• Thrombo-embolism
• Puncture of arteries
• Pneumothorax
• Bleeding.

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 Temporary Trans Thoracic Pacemaker

• Transthoracic pacing means using wires inserted during

cardiac surgery ( Aorta valve surgery, tricuspid valve
surgery, ventricular septal defect closure) Small wires
are placed on he epicardial wall of the heart that lead out
of the chest, to a pulse generator. The same pulse
generator can be used as in the transvenous pacemaker.
Atrial pacing and ventricle pacing can be used.

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Temporary Trans Thoracic Pacemaker

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 Permanent pacemakers and leads:

Permanent pacemakers consist of a battery, a pulse

generator and a computer circuit and flexible leads which
are usually placed in the right atrium and right ventricle

Example of a pacemaker

Example of pacemaker leads

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Pulse–generator permanent pacemaker
Connection block for leads or “ wires”

Housing or “can”

leads

Active sensor

Battery

Electrical circuitry

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 Three types of pacemakers

Single Chamber Dual chamber Biventricular

pacemaker pacemaker pacemaker

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Single Chamber Pacemaker

In this example one pacing lead in te right ventricle

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 Dual chamber Pacemaker

One pacing lead in the atrium, one pacing lead in the right ventricle

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 Biventricular Pacemaker

One pacing lead in atrium, one pacing lead in right ventricle.

One pacing lead via the sinus coronaria to the left ventricle
In Cardiac Rechronization Therapy

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 Pacemaker leads

• Pacemaker leads are flexible wires which transport the

electrical impulse from the generator to the myocardium
The connection of these leads on the pacemaker is
internationally standardized, so that pacemakers and
leads from different manufacturers are interchangeable.

• Leads usually last longer than device batteries, so leads

are simply reconnected to each new pulse generator
(battery) at the time of replacement

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 Electrodes of the leads

• Cathode:
An electrode that is in contact with the heart
Negatively charged

• Anode:
Receives the electrical impulse after depolarization
of cardiac tissue
Positively charged when electrical current is flowing

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 Unipolar Pacing System
• The lead has only one electrode – the
cathode – at the tip
• The pacemaker “can” is the anode
Anode
• When pacing, the impulse:
+
– Flows through the tip electrode
(cathode)
– Stimulates the heart
– Returns through body fluid and
tissue to the pacemaker can
(anode)

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 Bipolar Pacing System
• The lead has both an anode and
cathode
• The pacing impulse:
– Flows through the tip
electrode located at the end of
the lead wire
– Stimulates the heart
– Returns to the ring electrode,
the anode, above the lead tip

Anode

Cathode
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Fixation Mechanisms of transvenous leads

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Cardiac Resynchronization Therapy
in Heartfailure

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http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/Classes- of-Heart-Failure_UCM_306328_Article.jsp

Classes of heartfailure

The New York Heart Association (NYHA) Functional Classification

Website:
http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/Classe
s- of-Heart-Failure_UCM_306328_Article.jsp

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 Heartfailure

• In approximately 25-50% of patients with heart failure there is an

abnormality in the heart’s electrical conducing system. It is called
an “intra ventricular conduction delay” or” bundle branch block”. It
is most commonly seen as a Left Bundle-Branch Block (LBBB)

ECG characteristics of a typical Left Bundle Branch Block showing

a wide QRS complexes in lead V1 and V6.

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 Ventricular dyssynchrony
• Ventricular dyssynchrony is a difference in the timing, or
lack of synchrony, of contractions in different ventricles
in the heart

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 Achieving Cardiac Resynchronization
Goal: Atrial synchronous
biventricular pacing
Right Atrial
Lead
Transvenous approach for left
ventricular lead via coronary sinus
Back-up epicardial approachLeft Ventricular
Lead

Right Ventricular
Lead

Biventricular Pacing : CRT improves survival, quality of life, heart function, the ability to exercise, and
helps decrease hospitalizations in select patients with severe or moderately severe heart failure.

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 A B C
In figure A: there is first contraction of the lateral wall of the left ventricle before contraction of the septal
wall of the left ventricle: dyssynchrony will lower the ejection fraction and decrease the cardiac output.
 
In figure B :there is first contraction of the septal wall of the left ventricle before contraction of the lateral
wall of the left ventricle: dyssynchrony will lower the ejection fraction and decrease the cardiac output
 
In figure C: Biventriclar pacing resynchronizes activation by contraction of the lateral and septal wall of the
left ventricle The ejection fraction is higher and the cardiac output is better

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Electrocardiogram before and after biventricular pacing

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46
What is an implantable Cardioverter
Defibrillator

It is very smiliar with a pacemaker. It

can prevent slow heart rates in
patients with bradycardia….

….. but it can do more !

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 ICD therapie
1. Anti tachycardia pacing

– Small rapid pacing signals are delivered when the

defibrillator detects atrial or ventricular tachyarrhythmia
– The patient will not feel this therapy
– If a normal rhythm is restored, no further treatment is
delivered. If not the next step can be cardioversion or
defibrillation

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 ICD therapie

2. Cardioversion

– The defibrillator detects Atrial fibrillation or Ventricle Tachycarida ( VT)

– The defibrillator can give stronger impulses with low to high energy
shock , if needed
– The shock(s) are given in a specifik time in the heart rhytm.
– It feels like a thump on the chest

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 ICD therapie
3.Defibrillation

– The defibrillator After detects ventricle fibrillation ( VF)

– It will give a high energy shock to the heart. This shock interrupts
the VF and can be restored to a normal heartrhytm
– During VF most patients lose consciousness. Patients who are
conscious describe the shock as “ a kick in the chest”

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 ICD Therapy B

VT

FVT

VF
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Setting of the shock therapy.

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 American College of Cardiology/ American Heart Asociation

Guidelines for Cardiac Rechronisation Therapy and Implantable Cardioverter

Defibrillator

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 Guidelines
Classification of Recommendations: Level of Evidence:

• Class I : • Level A
Conditions for which there is evidence and/or general :Data derived from multiple randomized clinical trials or
agreement that a given procedure or treatment is meta-analyses.
beneficial, useful, and effective.
• Level B
• Class II: :Data derived from a single randomized trial or
Conditions for which there is conflicting evidence and/or nonrandomized studies.
a divergence of opinion about the usefulness/efficacy of
a procedure or treatment. • Level C:
• Class IIa: Only consensus opinion of experts, case studies, or
Weight of evidence/opinion is in favor of standard-of-care.
usefulness/efficacy.
• Class IIb:
Usefulness/efficacy is less well established by
evidence/opinion.

• Class III Conditions for which there is evidence and/or

general agreement that a procedure/treatment is not
useful/effective and in some cases may be harmful.

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 RECOMMENDATIONS FOR CARDIAC RESYNCHRONIZATION THERAPY
• Class I Recommendations IN PATIENTS WITH SYSTOLIC HEART FAILURE
• . Non-LBBB pattern
• CRT is indicated for patients who have*
• . QRS duration . 150 ms
• . LVEF . 35% . Sinus rhythm
• . Left Bundle Branch Block (LBBB) . QRS duration . 150 ms • . NYHA class III, or ambulatory Class IV symptoms
• . NYHA class II, III, or ambulatory . Guideline-Directed Medical • . Guideline-Directed Medical Therapy
Therapy • (Level of Evidence: A)
• Class IV symptoms • CRT can be useful for patients who have:
• (Level of Evidence: A for NYHA class III/IV; Level of Evidence: B for
• . Atrial fibrillation
NYHA class II)
• Class IIa Recommendations
• . LVEF . 35%
• CRT can be useful for patients who have: • . Guideline-Directed Medical Therapy
• . LVEF . 35% • If a) the patient requires ventricular pacing or
• . Sinus rhythm otherwise meets CRT criteria and b) AV nodal
• . LBBB ablation or pharmacologic rate control will allow
• . QRS duration 120 to 149 ms near 100% ventricular pacing with CRT.
• . NYHA class II, III, or ambulatory Class IV symptoms • (Level of Evidence: B)
• . Guideline-Directed Medical Therapy • CRT can be useful for patients who have:
• (Level of Evidence: B) • . LVEF . 35%
• CRT can be useful for patients who have: • . Guideline-Directed Medical Therapy
• . LVEF . 35% • . Anticipated requirement for signific
• . Sinus rhythm
• ant (> 40%) ventricular pacing
• (Level of Evidence: C) 2012 ACCF/AHA/ HRS focused update of the 2008 Guidelines for device- based Therapy of
Cardiac Rhytm Abnormalitys :
e

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 RECOMMENDATIONS FOR IMPLANTABLE CARDIOVERTER DEFIBRILLATORS
2012 ACCF/AHA/ HRS focused update of the 2008 Guidelines for device- based Therapy of Cardiac Rhytm Abnormalitys :

• Class I Recommendations • Klaas IIa Recommendations

• ICD therapy is indicated in patients*: • ICD implantation is reasonable for patients*:
• Level of Evidence: A. • Level of Evidence: B
• With LVEF . 35% due to prior MI who are at least 40 days post-MI • To reduce SCD in patients with Long QT Syndrome who are
and are in NYHA Functional Class II or III experiencing syncope and/or VT while receiving beta blockers
• With LV dysfunction due to prior MI who are at least 40 days post- • Level of Evidence: C
MI, • With unexplained syncope, significant LV dysfunction, and
• have an LVEF . 30%, and are in NYHA Functional Class I nonischemic DCM
• Who are survivors of cardiac arrest due to VF or • With sustained VT and normal or near-normal ventricular
hemodynamically unstable sustained VT after evaluation to define function
the cause of the event and to exclude any completely reversible
• With catecholaminergic polymorphic VT who have syncope
causes
and/or documented sustained VT while receiving beta
• Level of Evidence: B.
blockers
• With nonischemic DCM who have an LVEF . 35% and who are in
• For the prevention of SCD in patients with ARVD/C who have
• NYHA Functional Class II or III one or more risk factors for SCD
• With nonsustained VT due to prior MI, LVEF < 40%, and inducible • With HCM who have one or more major risk factors for SCD
VF or sustained VT at electrophysiological study
• With Brugada syndrome who have had syncope or
• With structural heart disease and spontaneous sustained VT,
documented VT that has not resulted in cardiac arrest
whether hemodynamically stable or unstable
• With cardiac sarcoidosis, giant cell myocarditis, or Chagas
• With syncope of undetermined origin with clinically relevant,
disease
hemodynamically significant sustained VT or VF induced at
electrophysiological study • For nonhospitalized patients awaiting transplantation

• *

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 Insertion of (Biventricular) Pacemaker /ICD
Preparation before the procedure: See Standard Operations Protocol SHG:

• Make ECG
• Explain the procedure to the patient.
• Stop anti-coagulans 4-6 days before procedure( instruction dokter)
• If necessary give low molecule heparin ( lovenox, arixtra)
• Check lab routine, CRP, Na ,K ,Ureum, Creatinine, glucose and INR.
• Patient need fasting at least 6 hours before.
• Shaving the area arteria clavicula in the insertion side
• Bring in iv acces.
• Give intravenous antibiotic 1 hour before as prescribed by Physician or SOP

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 The procedure
• The patient will be placed in a supine (on your back) position on
• The leads wire will be inserted through the introducer into
the procedure table.
the blood vessel. The physician will advance the lead wire
• The patient will be connected to an electrocardiogram (ECG or
EKG) monitor that records the electrical activity of the heart and
through the blood vessel into the heart.
monitors the heart during the procedure. The vital signs (heart • Once the lead wire is inside the heart, it will be tested to
rate, blood pressure, breathing rate, and oxygenation level) will verify proper location and that it works. Fluoroscopy, (a
be monitored during the procedure. special type of x-ray that will be displayed on a TV
• Large electrode pads will be placed on the front and back of the monitor), may be used to assist in testing the location of
chest. the leads.
• The patient will receive a sedative medication via IV acces before • Once the lead wires have been tested, an incision will be
the procedure to help him/her relax. However, the patient will made close to the location of the catheter insertion (just
likely remain awake during the procedure.
under the collarbone). The patient will receive local
• The pacemaker or ICD insertion site will be cleansed with
anesthetic medication before the incision is made.
antiseptic soap.
•
• The pacemaker/ICD generator will be slipped under the
Sterile towels and a sheet will be placed around this area.
skin through the incision after the lead wire is attached to
• A local anesthetic will be injected into the skin at the insertion site.
the generator. Generally, the generator will be placed on
• Once the anesthetic has taken effect, the physician will make a
the non-dominant side. (If you are right-handed, the
small incision at the insertion site.
device will be placed in your upper left chest. If you are
• A sheath, or introducer, is inserted into a blood vessel, usually
left-handed, the device will be placed in your upper right
under the collarbone. The sheath is a plastic tube through which
the pacer/ICD lead wire will be inserted into the blood vessel and chest).
advanced into the heart. • The ECG will be observed to ensure that the pacer is
• It will be very important for the patient to remain still during the working correctly.
procedure so that the catheter placement will not be disturbed • The skin incision will be closed with sutures, adhesive
and to prevent damage to the insertion site. strips, or a special glue.
• A sterile bandage/dressing will be applied.

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 Directly after procedure
• The physician will test the pacemaker with/ without ICD and program it with
the special programmer. The patient will be given general anesthesia in
case of testing the ICD by a shock test.
• Check regularly vital signs and the condition of the wound
• Check the 12 leads ECG and check the ECG monitor
• The patient has to be in a position of 30 degrees during a couple of hours
and can not lay down on the left or right side to avoid dislocation
• Use extra pressure ( sandbag) if there is a hematoma or bleeding.
• Give intravenous following instruction of the physician.
• Check lab values following instruction of the physician.
• Give the prescribed pain medication

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 The next day after procedure

• Check ECG and x-ray to see the position of the leads and generator.
• The pacemaker/ ICD has to be checked by the technician with the special
programmer.
• Use a mitella if the generator was inserted in the musculus pectoralis during 2
days
• Restart anti coagulans in case the patient use before the procedure
• Check the wound and change dressing if necessary.
• Give the prescribed intravenous antibiotic
• The patient can be mobilize: slowly getting up from the bed to avoid dizziness.
• Give the prescribed pain medication.
•

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 Instruction related to the procedure before going home

• Instruct the patient to keep the wound clean.

• Instruct patient to remove the sutures after 10 days in the hospital
• Give patient a Pacemaker/ICD identity card with the type of the pacemaker
and the type of the leads.
• Instruct patient to do regularly shoulder exercise to prevent a frozen
shoulder.
• The patient has to be instructed not do lifting or pulling on anything for a few
weeks The patient will be instructed not to lift the arms above the head for a
period of 6 weeks to prevent dislocation or migration of the leads.

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 Instruction before going home related to the device

• Mobile phones are safe if it used normally. However mobile phones can cause interference when
the phone is placed directly over the implant site. Cell phones has not to be put in the shirt pocket
and leave it on.
• Electromagnetic security detectors ( in malls or airport) can cause interference depending of the
duration. Advice is to move through the security system at a normal pace and not to linger around
the device for an extended period of time. Screeners has to know the patient has a pacemaker
and the patient has to show the PM ID card.
• motor-generator sytems (i.e. car dynamo) can interfere with pacemaker programming. In general
advice is to stay at least two feet away from such equipment.
• Although several newer pacemakers are special designed for MRI Magnetic Resonance
Imaging is dangerous because the strong magnetic field can dislodge the electrodes form the
heart causing myocardial damage, and it can also interfere with the programming of the
pacemaker.
• Physical activity and recreational sporting activity can be done after 6 weeks but the patient has
tobe carefull for trauma during sport.
• If the patient has a surgical procedure the patient has to inform the surgeon.Using electrocautery
can interference with the pacemaker and change the settings.

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 Complications related to insertion of a
pacemaker/ Implantable Cardioverter Defibrillator

Complications of a pacemaker/ICD implantation is

depending on the location of the venous acces,
leads , pocket and generator. Complications can
occur directly after the insertion/ implantation but
can also occur later.

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 Venous acces related complications
• Pneumothorax
• This complication is directly related to operator experience, the difficulty of
the subclavian puncture.It is often asymptomatic and noted on routine chest
x-ray, but occasionally it requires active medical treatment with intercostals
chest drain and aspiration.
• Hematothorax.
• This complication results from trauma to the great vessels
• Air embolism
• Deep inspiration at the time of central venous access may cause significant
air to be drawn into the venous system due to the physiological negative
pressure
• developed.

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 Pocket related complications:
• Hematoma
A Pocket hematoma occurs most of the time directly after the implantation procedure.
Occasionly the wound has to be re-opened to stop the bleeding. Pressure with a sand-
pack can stop the bleeding
• Erosion and wound dehiscense
A too small subcoutaneous pocket for the generator and tension on the underlying
skin may cause tissue and skin erosion. There is a high risk for infection. It can be
nesseccary to remove and re-implant the generator including new leads  
• Wound pain
Minor wound pain is expected after device implantation and can be controlled with
simple analgesia.  
• Infection
As with any medical or surgical procedure there is a risk of infection after the
procedure.To prevent an infection the patient will be treated with antibiotica
intravenous before and after the implantation procedure. If an infection occurs surgery
is necessary to replace the generator including new leads.

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 Lead related complications
• Cardiac perforation:
Lead perforation is a less-recognized delayed complication of device implantation. It can cause
pericardial effusion and tamponade It can be recognized by the clinical symptoms of chest pain,
dyspnoea and hypotension. A chest x-ray, echocardiographic evaluation and CT scan can
contribute in the diagnose However if it is recognized too late it can be fatal.it requires
occansionly active medical treatment with a pericardpunction. 
• Malposition or of the lead(s) :
• The small screw or hook of the end of the end of the lead do not make a good contact with the
myocardial tissue. Higher pacing and sensing thresholds can be measured with the programmer
A re-procedure has to be done for reposition or the leads has to be replaced 
• Lead dislodgement.:
• The leads are totally out of position and occur most of the time within the first 6 weeks after
implantation.Lead replacement is necessary. Lead dislodgement can occur due to conscious or
unconscious manipulation of the pulse generator. The patient rotate the generator around its long
axis. ( Twiddler’s syndrome) 
• Lead fracture:
• A pacemaker lead fracture can be a result of compression of the lead or leads between the
clavicle and the first rib.( sublavian crush syndrome)

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 Generator related complications:

• Set screw loose

There is a disconnection between the generator and the lead(s)
Most of the time it occurs in the first days after the implantation and
the pacemaker pocket needs to re-open to connect the generator
and the lead(s) again.

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 ICD specific complications
• Inappropriate shocks
• = shocks which are delivered by the ICD when there is no life-
threatening arrhytmia, such as VT or VF
• Oversensing
• T wave sensing
• Electromagnetic interference of electrical circuits from
outside.

Inappropriate shocks may have adverse effects on myocardial

function and increase the risk of death. Th ICD needs
immediately reprogrmmed by a programmer

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 Other complications
• Superior vena cava syndrome (SVC)
SVC syndrome is a set of symptoms that result when vene from the superior vena
cava to the heart is narrowed or blocked. Symptoms are due to increased pressure
in the superior vena cava caused by the pacemaker and/or leads. The symptoms can
be swelling in the legs arms or face, also shortness of breath and widening of the
veins in the neck and chest. It could be a reason to replace the leads or the
pacemaker 
• Pericarditis:
This is a rare complication after pacemaker implantation. The cause could be the
active fixation ( with screw or hook) form the pacemaker leads 
• Pacemaker syndrome:
A set of symptoms due to a wrong timing (dyssynchrony) between the atria
contaction and the ventricle contraction. ( no “ atrial kick”)This can lead to low a low
cardiac output with symptoms of fainting or shock. To prevent this complication the
pacemaker has to be re-programmed .

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 Follow up patients with a pacemaker /ICD:
Interrogation

Interrogation:
the check of the function of the Pacemaker / ICD by a special programmer

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 Follow up patients with a pacemaker/ ICD
Telemonitoring
Patient can be followed at home without visit the hospital

1.Pacemakers and ICD’s are pre-equipped with a micro transmitter.

2.Pacemaker/ICD will send data to an external device
3. External device will send data through wireless GSM
4.Data will be send to a central processing center and the data will be uploaded in a special website.
5. Doctor/ specialized nurse/ technicus can see the events of the pacemaker /ICD
6. In case of life threatening events the docter/nurse/technicus will contact the patient to come to the
hospital.

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The role of nursing in Cardiac Pacing

The number of patients who have an indication

for a pacemaker and/or ICD is increasing. The
organization of the cure and care for patients
with cardiac pacing has to be good organized.
Nurses need special competention and
certification for optimizing these cure and care.

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 The role of nursing in Cardiac Pacing
• Observation of Rhytm and conduction disturbance in cardiac care wards
• Starting up transcutaneous pacing in emergency wards
• Role in inserting temporary transvenous pacemaker
• Observation in Cardiac care wards in recognize complication and function
in patients with temporary transvenous pacemaker pacemakers
• Preparation and after care in insertion permanent pacemaker or
implantable cardioverter defibrillator.
• Special knowledge of programmers and interrogation in patients with
pacemaker/ICD
• The role of nursing in daily report in Telemonitoring systems.
• The role of nursies in psychological support.

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