Seminar on

Pacemaker

Submitted to Submitted by

Mrs Suseela P Suvarna V S

Associate Professor Ist year MSc Nursing

Govt College of Nursing Govt College of Nursing

Thiruvananthapuram Thiruvananthapuram

Submitted on

21/07/2014

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 Seminar on
Pacemaker

Submitted to Submitted by

Mrs Ponnamma K M Suvarna V S

Professor Ist year MSc Nursing

Govt College of Nursing Govt College of Nursing

Thiruvananthapuram Thiruvananthapuram

Submitted on

21/07/2014

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Central Objective

At the end of the class the students will be able to understand the Pacemaker and its
practical implications and appreciate its use in the clinical practice.

Specific Objectives

At the end of the class the students will be able to

1. define pacemaker
2. identify the purpose of pacemaker
3. understand the indications of pacemaker
4. describe temporary and permanent pacemaker
5. describe the pacemaker design
6. explain the methods of pacing
7. identify the pacemaker modes
8. understand the pacemaker functions
9. explain the pacemaker failure
10. classify pacemaker systems
11. manage a patient with pacemaker
12. list down the complications of pacemaker

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PACEMAKER – definition

A pacemaker (or artificial pacemaker) is a medical device that uses electrical impulses,
delivered by electrodes contracting the heart muscles, to regulate the beating of the heart.

PURPOSE

The primary purpose of a pacemaker is to maintain an adequate heart rate, either because the
heart's natural pacemaker is not fast enough, or there is a block in the heart's electrical
conduction system.

INDICATIONS

A pacemaker is indicated if the conduction system fails to transmit impulses from the sinus node
to the ventricles, to generate an impulse spontaneously, or to maintain primary control of the
pacing function of the heart.

Conditions that may necessitate a Pacemaker

 Ablation
 Acute myocardial infarction
 Autonomic nervous system failure
 Cardiac surgery
 Drug toxicity ( antidysarrhythmics)
 Electrolyte imbalance
 Myocardial ischemia

TEMPORARY PACING
This is usually instituted to provide immediate stabilization prior to permanent pacemaker
placement or to provide pacemaker support when a bradycardia is precipitated by what is
presumed to be a transient event such as ischemia or drug toxicity.
Temporary pacing is usually achieved by the transvenous insertion of an electrode catheter with
the catheter positioned in the right ventricular apex and attached to an external generator. This
procedure is associated with a small risk of cardiac perforation, infection at the insertion site, and
thromboembolism; the risk of the latter two complications increases markedly if the pacing wire
is left in place for 48 h.

PERMANENT PACING
This mode of pacing is instituted for persistent or intermittent symptomatic bradycardia not
related to a self-limiting precipitatingprecipitating factor or for documented infranodal second-
or third-degree AV block. Permanent pacing leads are usually inserted transvenously through the
subclavian or cephalic vein with the leads positioned in the right atrial appendage for atrial

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pacing and the right ventricular apex for ventricular pacing. The leads are then attached to the
pulse generator, which is inserted into a subcutaneous pocket below the clavicle. Epicardial lead
placement is used when (1)transvenous access cannot be obtained; (2)the chest is already open,
i.e., in the course of a cardiac operation; and (3)adequate endocardial lead placement cannot
be achieved. Most pacemaker generators are powered by lithium batteries. The life expectancy of
the generator is related to
(1)voltage output required for capture,
(2)requirement for incessant or intermittent pacing
(3)number of cardiac chambers paced.
Life expectancy of the simple ventricular demand pacemaker can exceed 10 years.

Clinical conditions that warrant Permanent pacemakers

A. Third-degree and advanced second degree atrioventricular block associated with the
following complications
 Symptomatic bradycardia (including Heart failure)
 Dysrhythmias and other medical conditions that require drugs that result in symptomatic
bradycardia
 Documented periods of asystole greater than or equal to 3 seconds
 After catheter ablation of the AV junction
 Post operative AV block that is not expected to resolve after cardiac surgery
B. Alternating bundle branch block
C. Sinus node dysfunction with symptomatic bradycardia, including frequent pauses

PACEMAKER DESIGN

A pacemaker provides an external energy source for impulse formation and delivery. The pulse
generator is essentially the pacemaker’s power source. It houses the electronic circuitry
responsible for sending out appropriate timed signals and for sensing the client’s cardiac activity.
The pulse generator can be external or internal. The external unit is designed for temporary
pacing. The unit is the size of a small transistor radio and operates by dry cell batteries. It has
dials for the adjustment of power, rate of discharge and mode. A pulse generator can also be
permanently implanted. The surgeon places the permanent pulse generator into a small tunnel
burrowed within the subcutaneous tissue below the right or left clavicle.
The pulse generator is small and contains a sealed lithium battery. Pacemaker generators can be
reprogrammed after insertion as needed. The output circuit controls the current pulse delivery
date, pulse duration, and refractory period. The sensing circuit is responsible for identifying and
analyzing any spontaneous intrinsic electrical activity and responding appropriately.
The lead delivers electrical impulse from the pulse generator to the myocardium. The leads
consist of flexible conductive wires enclosed by insulating material. The electrode is the end of

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the lead that delivers the impulse directly to the myocardial wall. It is usually made of Platinum
or iridium.
Electrodes can be unipolar or bipolar. Unipolar incorporates the cardiac electrode as the negative
terminal of the electrical circuit; the metallic shell or second wire of the impulse generator is the
positive electrode. Bipolar system uses two wires, each ending in an electrode a short distance
apart.

METHODS OF PACING

Percussive pacing

Percussive pacing, also known as transthoracic mechanical pacing, is the use of the closed fist,
usually on the left lower edge of the sternum over the right ventricle in the vena cava, striking
from a distance of 20 – 30 cm to induce a ventricular beat (the British Journal of
Anesthesia suggests this must be done to raise the ventricular pressure to 10 - 15mmHg to induce
electrical activity). This is an old procedure used only as a life saving means until an electrical
pacemaker is brought to the patient.

Transcutaneous pacing

Transcutaneous pacing (TCP), also called external pacing, is recommended for the initial
stabilization of hemodynamically significant bradycardias of all types. The procedure is
performed by placing two pacing pads on the patient's chest, either in the anterior/lateral position
or the anterior/posterior position. The rescuer selects the pacing rate, and gradually increases the
pacing current (measured in mA) until electrical capture (characterized by a wide QRS
complex with a tall, broad T wave on the ECG) is achieved, with a corresponding pulse. Pacing
artifact on the ECG and severe muscle twitching may make this determination difficult. External
pacing should not be relied upon for an extended period of time. It is an emergency procedure
that acts as a bridge until transvenous pacing or other therapies can be applied.

Epicardial pacing (temporary pacing)

Temporary epicardial pacing is used during open heart surgery should the surgical procedure
create atrio-ventricular block. The electrodes are placed in contact with the outer wall of the
ventricle (epicardium) to maintain satisfactory cardiac output until a temporary transvenous
electrode has been inserted.

Transvenous pacing (temporary)

Transvenous pacing, when used for temporary pacing, is an alternative to transcutaneous pacing.
A pacemaker wire is placed into a vein, under sterile conditions, and then passed into either the
right atrium or right ventricle. The pacing wire is then connected to an external pacemaker

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outside the body. Transvenous pacing is often used as a bridge to permanent pacemaker
placement. It can be kept in place until a permanent pacemaker is implanted or until there is no
longer a need for a pacemaker and then it is removed

Subclavicular pacing

Permanent pacing with an implantable pacemaker involves transvenous placement of one or

more pacing electrodes within a chamber, or chambers, of the heart, while the pacemaker is
implanted inside the skin under the clavicle. The procedure is performed by incision of a suitable
vein into which the electrode lead is inserted and passed along the vein, through the valve of the
heart, until positioned in the chamber. The procedure is facilitated by fluoroscopy which enables
the physician to view the passage of the electrode lead. After satisfactory lodgement of the
electrode is confirmed, the opposite end of the electrode lead is connected to the pacemaker
generator.

There are three basic types of permanent pacemakers, classified according to the number
of chambers involved and their basic operating mechanism:

 Single-chamber pacemaker. In this type, only one pacing lead is placed into a chamber of
the heart, either the atrium or the ventricle.
 Dual-chamber pacemaker. Here, wires are placed in two chambers of the heart. One lead
paces the atrium and one paces the ventricle. This type more closely resembles the
natural pacing of the heart by assisting the heart in coordinating the function between the
atria and ventricles.
 Rate-responsive pacemaker. This pacemaker has sensors that detect changes in the
patient's physical activity and automatically adjust the pacing rate to fulfill the body's
metabolic needs

Intracardial

Intracardial pacemakers are placed inside the heart. They are some 10 percent the size of a
subclaviculars. Such pacemakers do not require leads to be connected to in the heart muscle from
the distant pacemaker device. Intracardials are implanted into the heart using a steerable catheter
fed into the femoral vein via an incision in the inner thigh. The device cannot be seen or felt
beneath the skin. No leads extend to break or detach, eliminating the need for traditional activity
restrictions. The pacemaker can be retrieved in the same manner in which it was implanted.

Pacemaker Modes
There are two basic types of pacemakers

1. Fixed Rate (non-demand or asynchronous)

Fixed rate pacemakers are designed to fire constantly at a preset rate without regard to the
electrical activity of the client’s heart. This mode of pacing is appropriate in the absence of any
electrical activity, but is dangerous in the presence of an intrinsic rhythm because of the potential

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of the pacemaker to fire during the vulnerable period of repolarization and initiate lethal
ventricular dysrhythmias.

2. Demand pacemakers contains a device that senses the heart’s electrical activity and fires
at a preset rate only when the heart’s electrical activity drops below a predetermined rate.

Pacemaker Function
A simple demand pacing system works in the following manner;

The cardiac cycle normally begins with the client’s own beat. The pacemaker’s sensor
sense whether the intrinsic beat has occurred; if not, the pacer sends out an impulse to begin
myocardial depolarization through a pulse generator. The impulse generator is said to “capture”
the myocardium and thereby maintain the heart rhythm.

For a predetermined amount of time after the pacemaker impulse, the pacemaker cannot
sense incoming signals. This feature prevents the pacer from sensing its own generated electrical
current and from acting again.

Pacemaker failure
Malfunctions can occur in the pacemaker’s sensor or pulse generator’

1. Failure to Sense

An ability of the sensor to detect the client’s intrinsic beats; as a result, the pacemaker sends out
impulses too early. A failure may be due to improper position of the catheter, tip or lead
dislodgement, battery failure, the sensitivity being set too low, or a fractured wire in a catheter.

2. Failure to Pace

A malfunction of the pulse generator. Component failure to discharge( Pace) can be due to
battery failure, lead dislodgement, fracture of the lead wire inside the catheter, disconnections
between catheter and generator, or a sensing malfunction.

3. Failure to Capture

A disorder in the pacemaker electrodes; the impulse do not generate depolarization. This
complication can result from low voltage, battery failure, faulty connections between the pulse
generator and catheter, improper position of the catheter, catheter wire fracture, fibrosis at the
catheter tip.

Clinical manifestations associated with pacemaker malfunction include;

 Syncope
 Bradycardia/ tachycardia
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  Palpitations

CLASSIFICATION SYSTEM FOR PACEMAKERS

FIRST LETTER- CHAMBER PACED

Indicates which chamber of the heart wiil be stimulated

 V = Ventricle
 A = Atrium
 D = Dual chamber (both atria and ventricles stimulated)

SECOND LETTER- CHAMBER SENSED

Indicates the chambers of the heart in which the lead is capable of recognizing intrinsic electrical
activity:

 V = Ventricle
 A = Atrium
 D = Dual chamber
 O = No sensing capability

THIED LETTER- MODE OF RESPONSE

Indicates how the pacemaker will act based on the information it senses:

 T = Triggered (may have energy output triggered)

 I = Inhibited (pacing output inhibited by intrinsic activity)
 D = Dual chamber (may be either inhibiting or triggering of both chambers)

FOURTH LETTER- PROGRAMMABLE FUNCTIONS

Indicates ability to change function once the pacemaker has been implanted:

 P = Programmable for one or two functions

 M = Multiprogrammable ability to change functions other than the rate or output

FIFTH LETTER- TACHYDYSRHYTHMIC FUNCTIONS

Indicate specific methods of interrupting tachydysrhythmias.

 B = Bursts of pacing
 N = Normal rate competition
 S = Scanning

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NURSING MANAGEMENT OF PATIENTS WITH PACEMAKERS

ASSESSMENT

Assess the client for subjective clinical manifestations of dysrhythmias and alterations in cardiac
output;

 Palpitations
 Syncope
 Fatigue
 Shortness of breath
 Chest pain
 Skipped beats felt in the chest
 The client may also feel anxiety, nervousness, fear, sleeplessness, or uncertainity
or hopelessness.

Objective clinical manifestations may include;

Diaphoresis, pallor or cyanosis, variations in radial and apical pulse, rhythm changes,
hypotension, crackles, and decreased mental acuity.

Explain the purpose of the pacemaker and the experience of having a pacemaker inserted to the
client and family. A preoperative ECG is obtained, and a patent IV line is maintained.
Prophylactic antibiotics may be given.

After insertion, monitor vital signs and pacemaker function. Initially instruct the client to avoid
excessive extension or abduction of the arm on the operative side. Perform passive range of
motion exercises on the arm.

Obtain paced and nonpaced ECGs. The location of pacemaker electrodes is determined by X ray.
The model and serial number of the pulse generator and leads, along with the date of
implantation and programmed functions of the initial implant are recorded.

Health education

Wound care

1. Assess your wound daily and keep the incision clean and dry until it heals.
2. Report any fever, redness, drainage, warmth and discoloration, or swelling to the
physician.
3. Avoid constrictive clothing which puts excessive pressure on the wound and the pulse
generator.

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 4. Avoid extensive “toying” with the pulse generator because this may cause pacemaker
malfunction and local skin inflammation.

Pacemaker management

1. Measure pulse rate as instructed by the physician in the wrist and neck.
2. Notify the physician if pulse rate is slower than the set rate, also report sensations of
feeling heart “racing”, beating irregularly, fatigue or dizziness.
3. Avoid being near the areas with high voltage, magnetic force fields or radiation that
can cause pacemaker problems.
4. Avoid being near large running motors and standing near high tension wires, power
plants, radio transmitters, large industrial magnets and arc welding machines. Riding
in a car is safe, but do not bring the pacemaker to within 6-12 inches of the distributor
coil of a running engine.
5. Client can operate televisions microwave oven, radio.
6. At all times carry a pacemaker identity card and wear a medical alert bracelet.
7. Avoid activity that might damage the pulse generator, such as playing football.
8. If radiation therapy has been prescribed to the area in which the pulse generator was
implanted, it must be relocated.
9. Do not lift more than 2-4 kg for the first 6 weeks after surgery.
10. Do not move your arms and shoulders vigorously for the first 6 weeks. Normal
activities can be resumed in 6 weeks.
11. Follow up should be done periodically.

COMPLICATIONS

Complications of permanent pacing

Causes of pacing system malfunction include undersensing, oversensing, loss of capture, loss of
output, inappropriate rate, inappropriate lead position, inappropriate mode, extracardiac
stimulation, true pulse generator failure, pacemaker-mediated tachycardia (in dual-chamber
pacemakers with DDD, VDD, and DDDR modes), pacemaker syndrome and inappropriate
fiddling of the pulse generator by the patient. Most pacing system malfunctions are benign, but
some can be life-threatening.
 Complications related to venous access include pneumothorax, haemothorax, and air
embolism.
 Lead-related complications include perforation, dislodgment, diaphragmatic stimulation,
and malposition (including passage into the left side of the heart via a septal defect).Cardiac
tamponade, usually due to chamber perforation, should be suspected whenever hypotension
occurs.
 Local pocket-related complications include haematoma, wound pain, pocket erosion, and
infection.

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  Pacemaker infection ranges from mild local pain and erythema to life-
threateningsepticaemia. The most common pathogens are coagulase-negative
staphylococci,Staphylococcus aureus Gram-negative enteric bacilli and mixed infections.
 Delayed complications of permanent pacing leads include venous thrombosis, exit block,
insulation failure, and conductor fracture. Late lead damage may be reduced by use of
axillary or cephalic venous access.
 Most modern pulse generators have an expected longevity of 5-9 years and unexpected
pulse generator (electrical) failure is rare.
 Lead-related problems (increased thresholds, decreased impedance) resulting in increased
current drain are the most common causes of premature battery depletion.
 Lithium-iodine batteries used in current pulse generators are not rechargeable and surgical
replacement of the entire generator is required.

Complications of temporary pacing

 Immediate complications include:
 Ventricular tachycardia or fibrillation
 Arterial puncture
 Pneumothorax
 Brachial plexus injury
 Late complications include:
 Ventricular arrhythmias
 Septicaemia (especially staphylococcal infection)
 Wrong position requiring repositioning
Pacemaker syndrome
Pacemaker syndrome refers to the occurrence of symptoms relating to the loss of atrioventricular
(AV) synchrony in patients with a pacemaker.

 Ventricular pacing has been shown to sacrifice the atrial contribution to ventricular output.
 In some cases, atrial contraction occurs against closed AV valves, producing reverse blood
flow.
 In response to decreased cardiac output, total peripheral resistance is usually increased in
order to maintain blood pressure but does not increase in some patients, resulting in
decreased blood pressure.
 This combination of decreased cardiac output with a loss of the usual compensatory
increase in total peripheral resistance contributes to the development of pacemaker
syndrome.
 The incidence of pacemaker syndrome has been estimated to range from 7% (symptoms
severe enough to warrant pacemaker revision) to 20% (mild to moderately severe
symptoms). Asymptomatic pacemaker syndrome is probably common and the true
incidence of pacemaker syndrome much higher.

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  In 1994 Furman redefined pacemaker syndrome as:
 Loss of AV synchrony
 Retrograde ventriculoatrial (VA) conduction
 Absence of rate response to physiological need
Most authorities now understand pacemaker syndrome as being related to nonphysiological
timing of atrial and ventricular contractions, which may occur in a variety of pacing modes. It
has been proposed that pacemaker syndrome should be renamed as AV dyssynchrony syndrome,
which better reflects the mechanism responsible for causing symptoms.
Risk factors
 Patients with sick sinus syndrome frequently have preserved AV conduction.
 As many as 90% of patients with preserved AV conduction may have VA conduction,
which predisposes them to pacemaker syndrome.
 Patients may have intact VA conduction not apparent at the time of implantation or may
develop VA conduction at any time after pacemaker implantation.
 Patients with noncompliant ventricles and diastolic dysfunction (eg the elderly and patients
with cardiomyopathy) are particularly sensitive to loss of the atrial contribution to
ventricular filling.
Prevention
 Most cases of pacemaker syndrome occur with ventricular pacing and so atrial pacing
should be used whenever possible.
 Alternatively, a dual-chamber system can be programmed to a long AV interval to promote
intrinsic conduction, as long as dyssynchrony related to marked first-degree AV block is not
present.
 Pacing parameters must be optimised, eg AV delay, to achieve physiological timing of atrial
and ventricular contractions
Presentation of pacemaker syndrome
 The most common symptoms include pulsation and fullness in the neck, dizziness,
palpitations, fatigue, light-headedness and syncope.
 Symptoms of heart failure may occur.
 Symptoms can vary considerably and also vary in severity.
 Signs are also variable and include hypotension, tachycardia, tachypnoea, raised JVP.
 There may be variations in pulses and fluctuating blood pressure.
 A drop of 20 mm Hg or more during ventricular pacing compared with that during atrial or
AV synchronous pacing is suggestive of pacemaker syndrome.
 Basal lung crepitations, tender and pulsatile liver and peripheral oedema may occur.
 Examination of the heart may demonstrate regurgitant murmurs and variability of heart
sounds.

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BIBLIOGRAPHY

Lippincott’s Nursing Procedures 5th Edition Wolters Kluwer Publications 2009 Page No: 459-
463
Black M Joyce Medical Surgical Nursing Clinical Management for Positive Outcomes 8th edition
Elsevier publications Philadelphia Page No: 1473-1477

Anne B. Curtis Fundamentals of Cardiac Pacing ,2010 Page 212-214

Chow AW, Lane RE, Cowie MR; New pacing technologies for heart failure. BMJ. 2003 May
17;326(7398):1073-7.

Murphy JJ; Current practice and complications of temporary transvenous cardiac pacing. BMJ.
1996 May 4;312(7039):1134.

Yarlagadda C; Pacemaker Failure, eMedicine, Feb 2009.

Ausubel K, Furman S; The pacemaker syndrome. Ann Intern Med. 1985 Sep;103(3):420-9.

Furman S; Pacemaker syndrome. Pacing Clin Electrophysiol. 1994 Jan;17(1):1-5.

Bayerbach D, Cadman C; Pacemaker Syndrome, eMedicine, Nov 2009.

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