Artificial PACEMAKER
Heart pacemaker
sinus node is sometimes called the heart's
"natural pacemaker." Each time the sinus node
generates a new electrical impulse; that impulse
spreads out through the heart's upper chambers,
called the right atrium and the left atrium. The
sinus node reaches threshold at a rate of 60 to
100 times per minute. Sensitive tissue in the right
atrium wall that begins the heartbeat is SA node .
Because this is the fastest pacemaker in the heart,
the SA node is the dominant pacemaker of the
heart. The AV node has an inherent rate of 40 to
60 beats per minute and the His-Purkinje system
can fire at a rate of 20 to 40 beats per minute.
Sinus tachycardia results when the SA node fires
faster than 100 beats per minute. The normal
rate for the SA node when the patient is at
rest is: 60 to 100 beats per minute. One of the
functions of the atrioventricular (AV) node is to :
slow the impulse arriving from the SA node
Definition
• Artificial Pacemakers are the electrode
devices that can be used to initiate the
heartbeat when the hearts intrinsic
electrical system cannot effectively
generate a rate adequate to support
cardiac output.
• Pacemakers is an electronic device used
to pace the heart when the normal
conduction pathway is damaged or
diseased.
• Artificial pacemaker is implanted to ensure
the rhythm of heart is restored and is
regular. This is necessitated in conditions
where the pacemakers of the heart is
dysfunctional causing irregularity of heart
rhythm.
FUNCTIONS of artificial PACEMAKERS
1. Stimulate cardiac depolarization
2. Sense intrinsic cardiac function
3. Respond to increased metabolic demand by
providing rate responsive pacing .
4. Provide diagnostic information stored by the
pacemaker .
5. Provides an electrical impulse in the absence
of a heart's normal conduction system
HOW PACEMAKER WORKS ?
• pacemaker consists of a battery, a computerized
generator and wires with sensors at their
tips(called as electrodes). The battery powers the
generator and both are surrounded by a thin
metal box. The wires connect the generator to
the heart.
• battery which usually lasts six to 10 years
depending on how advanced the device
• The pacemaker is a small metal box weighing
20-50g. It helps monitor and control the
heartbeat. The electrodes detect heart’s electrical
activity and send data through the wires to the
computer in the generator. If heart rhythm is
abnormal, the computer will direct the generator
to send electrical pulses to heart. The pulses
travel through the wires to reach the heart.
Types of pacemakers
• Percussive Pacing
• Transcutaneous Pacing
• Transvenous Pacing
• Permanent pacing
1. Single-Chamber Pacemakers
2. Dual-Chamber Pacemakers
• Temporary pacemaker
• Fixed rate pacemakers
– set to work at a certain heart rate
– If the heart’s own intrinsic rate dropped
below a pre-set number the pacemaker
would begin to pace at a preset rate.
Percussive Pacing
• Strike from a distance of 20-30 cm with
closed fist on the left lower edge of
sternum.
• The pressure in the ventricle should rise 10-
15 mm hg
Types of permanent pacemakers
1.Single-chamber pacemaker.
In this type, only one pacing lead is placed into a
chamber of the heart, either the atrium or the ventricle
2- Dual-chamber pacemaker.
Wires are placed in two chambers of the heart . One lead
paces the atrium and one paces the ventricle . Closely
resembles the natural pacing of heart.
3- Rate-responsive pacemaker.
It has sensors that detect changes in the patient's physical
activity and automatically adjust the pacing rate to fulfill
the body's metabolic needs.
Indication of temporary pacemakers
• Maintenance of adequate heart rate and rhythm during
special circumstances such as surgery and
postoperative recovery, cardiac catheterization or
coronary angioplasty .
• Before implantation of a permanent pacemaker.
• As prophylaxis after open heart surgery.
• Acute anterior MI with second degree or third degree
AV block or bundle branch block.
• Acute inferior MI with symptomatic bradycardia and
AV block
IMPLANTATION PROCEDURE
• The procedure is usually done under local anaesthesia
• The pulse generator is implanted under the skin
• The leads are inserted using x-ray control, via a vein
found in this area, and positioned in the appropriate
right sided heart chamber
• The leads are tested before the pulse generator is
attached
• Although the incidence of pacemaker complications is
relatively low (about 4%), when complications occur,
they typically happen in the pocket where the
pacemaker is implanted or with the leads.
• In about 1% of patients, the pocket may become
infected. In about 3% of patients, the leads may move
out of place causing complications.
• While rare, complications can have a serious impact on
a patient’s quality of life and also can be expensive to
address. Even if complications do not occur, all
patients have a scar and lump where pacemaker is
implanted.
• In addition, previous research has shown that as many
as six out of 10 patients experience reduced mobility in
the shoulder region where the pacemaker is implanted
• With the development of leadless pacemakers, the
surgical pocket and leads are eliminated, which means
reducing the risks associated with these complications.
• Other possible advantages of the leadless pacemaker
include no visible pacemaker device under a patient's
chest skin, no incision scar on the chest and no
restrictions on a patient's activities.
• The device's benefits may also allow for less patient
discomfort, infections, and device complications and
dysfunction.
• In addition, the free-standing, battery-operated
pacemaker device is designed to be fully retrievable
from the heart.
Types of temporary
There are 4 types of temporary pacemaker.
1- Trans venous invasive pacemaker (endocardial)
• With a transvenous pacemaker, the pacer wire is
inserted through a large vein into the right ventricle,
with the leads attached to external pulse generator box.
• It consists of lead or leads or wire is inserted through a
large vein into that are threaded transvenously to the
right atrium and or right ventricle and attached to
external power source.
• Transvenous pacemakers are inserted into the venous
system through a catheter site such as a specially
designed pulmonary artery catheter, and deliver the
stimulus via electrodes that are in direct contact with
the heart tissue itself.
• Generally the subclavian, femoral or internal jugular
veins are used to access the right atrium or the right
ventricle.
2- Transthoracic invasive pacing (Epicardial pacing )
• Commonly used with cardiac surgery patients
undergoing an open thoracotomy.
• Temporary lead wires are inserted through the chest
(during heart surgery), and are directly connected to
the outermost layer of the heart. These wires exposed
through the skin, and connected to an external pulse
generator , which delivers a current to the heart to
make it beat normally.
• The leads are passed through the chest wall and
attached to the external power source.
3. Trans cutaneous pacemaker(Non-invasive pacing)
• Transcutaneous external pacing is primarily for
unstable rhythms in emergency situations, requiring
two electrodes on the chest, either in the
anterior/lateral position or the anterior/posterior
position
• By continuously monitoring cardiac rate and rhythm
and delivering pacing impulses through the skin and
chest wall muscles as needed, trancutaneous pacing
causes electrical depolarization and subsequent
cardiac contraction to maintain cardiac output until
the patient receives a transvenous pacemaker
• The pacing stimulus travels through chest wall,
pectoralis and intercostals muscle and fat before finally
reaching the heart. Therefore a much higher energy
level is needed to deliver the correct energy to the
heart. One side effect of this is chest muscle
contraction from the electrical stimulus. Therefore
giving the patient some sedation for comfort is high
priority
• Pacing or defibrillation pads must be in good contact
with chest wall
Transesophageal pacing
Transesophageal pacing involves placing an electrode in
the esophagus through the nose or by a pill-electrode that
is swallowed. The electrode connects to an external pulse
generator by a wire. This type of pacing is commonly
used only for atrial pacing in sinus bradycardia or for
diagnostic studies.
 Leadless Pacemaker Implantation

1. A catheter that 2. Using X-ray images as a 3. The catheter with the

contains the leadless
guide, the doctor guides the pacemaker is then guided
pacemaker is passed
catheter to the right atrium of into the right ventricle.
through a small
the heart and through the
puncture in the groin
tricuspid valve.
and then into the
femoral vein.

4. The doctor carefully 5. The pacemaker is then 6. The catheter is

places the pacemaker tested to ensure it is removed and the
and secures it to the wall secured to the wall and pacemaker stays
at the bottom of the right programmed correctly. within the right
ventricle. ventricle.
 Leadless Pacemaker Design
• Similar to standard cardiac pacemakers, leadless
pacemaker device treats a heart rate that is too
slow called bradycardia. It works by closely
monitoring the heart's electrical rhythms and if
the heart beat is too slow (or in an irregular
pattern) it provides electrical stimulation
therapy to regulate it. It also communicates to a
programming system, like a standard pacemaker
• Unlike standard pacemakers, leadless
pacemaker is designed as a small cylindrical
pacemaker.
• The device is comprised of a pulse generator
that includes computer chips, small long lived
battery in a sealed case that resembles battery
and electrode that sends pulses to the heart when
it recognizes a problem with the heart’s rhythm.
• The device, resembling a small, metal silver
tube, is only a few centimeters in length, making
it less than ten percent the size of a standard
pacemaker.
• But, unlike standard pacemakers, it resides
entirely in the right ventricle of your heart.
• This pacemaker requires no leads, no chest
incision, no scar and no permanent lump under
the skin where the pacemaker sits. The
pacemaker battery life is equivalent to that of
similar standard single chamber pacemakers.
Investigation to assess pacemaker
• Blood tests: electrolytes, coagulation screen,
digoxin levels if appropriate, myocardial injury
markers - eg, troponins
• 12-lead ECG - any sign of myocardial
ischaemia, arrhythmias or abnormal sensing
• CXR: evaluate lead position and look for lead
fracture
• Echocardiogram: to assess for lead position,
pericardial effusion or tamponade, or lead
fracture
• Pacemaker assessment .
• A successful routine for pacemaker insertion has
been established which includes fluoroscopy,
lateral roentgenograms, intracardiac and surface
electrocardiograms,
• Roentgenogram, also
called roentgenograph or X-ray image,
photograph of internal structures that is made by
passing X-rays through the body to produce a
shadow image on specially sensitized film by
the use of contrast material, such as barium, to
make structures visible on the film
Nursing management
Preoperative care
Financial
1. Explain the procedure ,type and technique of
pacemaker to the patient
2. Explain Cost of the procedure and Hospital
stay.
Psychological
1. Explain the Process of the pacemaker insertion .
2. Reassure the patient
Physical
1. Obtain written consent from the patient and
from nearest relative
2. Remove dentures , jewellery and contact lens.
3. Clean and shave the area .
4. Check vital signs: temperature, BP, pulse and
respiration
5. Teach range-of-motion (ROM) exercises for the
affected side ROM exercises of the affected arm
and shoulder prevent stiffness and impaired
function following pacemaker insertion.
Intraoperative care
1. Check serology: HIV, HbsAg, HCV and others
2. Start an IV line with 5% Dextrose solution or
normal saline solution.
3. Check the battery in pulse generator
4. Prepare the emergency cart, the defibrillator
and jelly , and the ECG monitor
5. Set up all equipment for the insertion of the
pacemaker
6. The nurse should know about the pacemaker
generator including the power switch, indicator
light for pacing and sensing, stimulus output
dial, sensitivity dial, and their proper settings.
7. Assist the doctor and the scrub nurse during the
procedure step by step
8. Observe vital signs and observe ECG monitor
carefully for arrhythmias and other
complications.
Post operative care
1. Receive the patient
2.Keep the patient in comfort position
3.Record the pacing parameters.
4.Receiving time
5.patient’s heart rate
6.Assess Signs of pacemaker malfunction to
report, including dizziness, fainting, fatigue,
weakness, chest pain, or palpitations.
Other routine care
1.Immobilize the affected part and keep in supine Complication
position but allow the movement of finger and ankle
joint. Operative failures
2.Monitor heart rate and rhythm.
• Pneumothorax may require chest drain.
3.Monitor vitals signs and level of consciousness of
patient. • Haemothorax
4. Prevent infection.
5.Take ECG and X-ray chest.. • Pericarditis
6. Watch for complications
• Air embolism
Discharge instructions to teach the patient:
• Erosion of the pacer through the skin (rare -
• Placement of the pacemaker generator & leads, how
it works,
requires pacer replacement and systemic
& the rate at which it is set.
• Monitor site for bleeding & infection for the first antibiotics.
week;
bruising may be present. Complications of temporary pacing Immediate
• Avoid immersing the site in water for 3 days.
• Minimize arm & shoulder activity of affected arm
complications include
and wear • ventricular tachycardia
loose covering over incision for 1-2 weeks, to
prevent • fibrillation
dislodgement of new leads. the patient is instructed
• Arterial puncture
to avoid lifting the arm on the pacemaker side above
the shoulder to avoid displacing the pacemaker
Pneumothorax :Late complications include
leads.
• Avoid contact sports and heavy lifting for 2 months • Ventricular arrhythmias
after
surgery. • Wrong position requiring repositioning
• Contact physician with fatigue, palpitations, or
• Septicemia (especially staphylococcal
recurrence
of symptoms (may indicate pacemaker malfunction infection).
or battery
depletion). Failure to output
• Avoid direct blows to generators or to large magnets
such as MRI scanner . These device can reprogram
a pacemaker. Instruct patients regarding Signs of
This may be due to battery failure, lead
pacemaker malfunction.
• Take radial pulse daily before arising & notify fracture, a break in lead insulation, over
physician for
rates outside those programmed (may indicate sensing (inhibiting pacer output), poor
pacemaker
malfunction or battery depletion). lead connection at the take off from the
• Carry pacemaker information at all times & wear a
MedicAlert pacer
bracelet (pacemaker will trigger some airport
security alarms). •Hiccups (A lead positioned near the
• Discuss any possible procedures with cardiologist
(some diaphragm can stimulate
procedures - MRI, electrocautery - may affect the
pacemaker).
• Household appliances such as microwave ovens,
it, may occur in extremely thin clients
radios, & gardening tools will not affect the
pacemaker. Cell phones currently don’t appear to or may indicate a medical emergency
affect pacemakers.
with perforation of the right ventricle by
• Maintain follow up care with a physician to check
the pacemaker site and begin regular pacemaker
the pacing electrode tip.
function checks .
• The nurse is caring for a patient who is on a cardiac
monitor. The nurse realizes that the sinus node is the
pacemaker of the heart because it is: the fastest
pacemaker cell in the heart.