Pacing Week

Presentations
Epicardial Pacing Overview
Literature Review: Epicardial Pacing Trends

Epicardial Pacing Procedures

Troubleshooting Pacing Problems

Epicardial Pacing
Overview
What is epicardial pacing?

An artificial electrical
impulse delivered to the
heart via the epicardial
surface to initiate
depolarisation
Why do patients need epicardial
pacing?
 CABG patients: cardiac output requires
augmentation, depends on extent of pre-
operative disease and incidence of arrhythmias
 Valve surgery patients: conduction system is
susceptible to injury during surgery, directly or
through subsequent oedema
 Interventricular septal defect repair
patients: suture placement in close proximity to
AV node and bundle of His.
 Components
 Pacing Box –
generates the
electrical impulse
 Epicardial wires –
inserted surgically at
the end of the
operation
 Cable leads –
connect epicardial
wires to the pacing
generator
These wires provide a direct, low resistance
current pathway to the myocardium.
 Pacemaker Settings
 Rate: number of impulses generated per
minute
 Output (Atrial & Ventricular): amount of
energy delivered with each impulse
 Sensitivity (Atrial & Ventricular): ability
of the pacemaker to sense intrinsic cardiac
activity

Settings required vary according to mode

Sensitivity - The higher the setting,
the less sensitive the pacemaker is.
For example, if the ventricular sensitivity is set on 2mV, it will
sense intrinsic activity that is greater in amplitude than
2mV. However, if the sensitivity is set at 10mV, the
pacemaker will only sense intrinsic activity that is greater
than 10mV.
10mV

2 mV

0.5 mV

At a lower setting (mV) the pacemaker is more sensitive

 Pacing Modes
 International code for identifying pacing
modes:
 First letter = Chamber Paced
 Second letter = Chamber Sensed
 Third letter = Response to pacing
 Chambers: A=Atria, V=Ventricle, D=Dual
 Responses: I=Inhibited, T=Triggered,
D=Dual
(‘O’ indicates a null value)
 Pacemaker Responses
 Inhibited - sensed intrinsic cardiac
activity will inhibit the pacemaker
from generating an impulse

 Triggered - a sensed event will

trigger another event.
Dual response:
 allows for an inhibited or a triggered
response (only possible in the dual
chamber mode)
 Example of dual response: sensed atrial
activity inhibits an atrial output but also
triggers an AV delay.
 If at the end of the AV delay there has
been no intrinsic ventricular output, the
pacemaker will generate an impulse.
 DDD Specific Settings
 Atrial Tracking: A sensed atrial event not only
inhibits atrial pacing but also triggers the AV
interval.
 A-V Interval: Aims to optimise cardiac output by
synchronising atrial and ventricular depolarisation
(often described as the “electronic” PR interval).
Length of time in milliseconds (ms) that is allowed to
elapse between a paced or sensed atrial event and the
delivery of a paced ventricular impulse.
 Upper Rate Limit: Maximum ventricular pacing
rate allowed while atrial tracking is on.
If atrial rate becomes too fast, upper rate limit prevents
atrial-tracking function from allowing a ventricular
response to continue past a safe rate. Limit is
determined by rate setting + 30PPM or 110PPM
(whichever is greater).

 PVARP (Post-ventricular atrial refractory

period): the length of time following a
ventricular event when atrial sensing is
inactivated. This avoids the pacemaker sensing
T-wave as atrial activity.
Setting automatically determined by the base rate
(<100 ->300ms, 100-150 ->250ms …)
 What mode is this?

VVI or…
DDD with Atrial Tracking ‘On’, AV interval 160ms

Explains why sometimes monitored rate is faster than

pacemaker rate setting – patient’s atrial rate is faster and
atrial tracking function is on
What mode is this?
Pacing
Box
Turning it on
 Press ON. The pacemaker will perform a
power on self-test that lasts about 4
seconds
 The back light will come on and Dual Chamber
pacing and sensing begins at preset values.
 Requires a 9V battery

NOTE: pressing the Emergency key also turns the

device on.
Default Values:

 Mode: DDD
 Rate 80
 A Output 10 mA
 V Output 10 mA
 A Sensitivity 0.5 mV
 V Sensitivity 2.0 mV
Emergency Key
 Pressing this key will initiate high output
dual chamber asynchronous pacing at
rate of 80 (or previous setting)
 What mode will this be?

 Pressing the ON key will resume Dual

Chamber Demand (synchronous)
pacing.
Lock/Unlock Key
 Locks and unlocks the three upper dials.
 When it is locked the padlock icon appears
and these values cannot be changed.
 Automatically locks after 60 seconds.
 ON, OFF, MENU, EMERGENCY, and PAUSE
keys also unlock the upper dials.
RETURN TO SESSION LIST
Literature Review:
Epicardial pacing
trends
PAH Statistics
 What is epicardial pacing used for
postoperatively?
Takeda, M. et al (1996) Cardiovasc. Surgery
 Reviewed reasons for pacing (used in 54% of
cardiac surgical patients):
 Rapid atrial pacing to interrupt SVT

 Improve cardiac output in bradycardic

patients
 Suppress PACs and atrial tachycardias

Recommendation - Should be used in preference

to antiarrhythmic medications post-op
Should all cardiac surgical patients
have epicardial pacing wires?
Puskas, J. et al (2003) Heart Surgery Forum
 Studied patients undergoing either
conventional CABG or off-pump CABG
 PW were placed prior to chest closure
according to criteria-driven protocols
 Bradycardia with low cardiac output
 nodal or junctional arrhythmias
 AV blocks
Findings:
 33 out of 197 (17%) of patients required

PW
 No patient without PW required pacing

postoperatively by any other means or

had other complications related to
avoidance of PW
Recommendation – current criteria driven
protocols are accurate in predicting which
patients require pacing postoperatively
 Does the pacing mode used
influence coronary graft flow?
D’Ancona, G. et al (2004) Eu J. Cardiothoracic Surg
 Studied CABG flow post weaning of CPB

 First study: compared flow rates between

DDD and VVI pacing modes
 Findings: DDD improves haemodynamic state
and therefore graft flow
 Second study: compared flow rates in
DDD mode with different AV intervals
 Findings – systemic haemodynamics are not
influenced by length of AV delay, however,
coronary graft flow is maximised at 175ms

Recommendations – in patients requiring

DDD pacing, an AV interval of 175ms is
optimal.
 Does atrial epicardial pacing
prevent AF after heart surgery?
Daoud, E. et al (2002) Journal of Cardiovascular
Electrophysiology
 Performed a meta-analysis to assess the effect
of pacing therapies for prevention of post-op AF
 Reviewed 8 trials, total 776 patients, looking at:
 Location of pacing wires – right atrial, left atrial or
biatrial
 Pacing algorithm - overdrive pacing (set rate 10
above sinus rate) v. fixed high-rate pacing (rates 80-
100)
 None of the trials used antiarrhythmics in
combination with pacing
Findings:
 Overdrive biatrial and right atrial pacing,

and fixed high-rate biatrial pacing

demonstrated a significant reduction in
incidence of AF (2½ times less likely)
Recommendations - Pacing therapy is
preferred to medications for AF
prophylaxis as it is less expensive & has
less risk of arrhythmia complications and
hypotension.
 Is biatrial (left & right) pacing
better at preventing AF than right
only?
Debrunner, M. et al (2004) Eu Journal of Cardiothoracic
Surgery
 Studied patients with no history of AF,
undergoing valve surgery +/- CABG
 Control group – standard atrial wires
 Treatment group - additional wire in L) atrium to
achieve bi-atrial pacing (BAP)
 Paced in AAI at a rate 10 above intrinsic rate, for
72hours post-op
Findings:
 Prophylactic BAP reduced the incidence of
AF by half when compared to control
group (BAP is thought to promote inter-
atrial synchrony).
 Over 60% of episodes of AF occurred
between 24-72hrs post-op.
Recommendations – BAP is more efficient at
preventing AF than conventional pacing
when used up to 72hrs post-op.
RETURN TO SESSION LIST
Epicardial Pacing
Procedures
 Changing Pacing Mode:
Demand/Synchronus Pacing
 On arrival from OT change patient to a
demand mode of pacing (eg. AAI, DDD)
 During demand (synchronous) pacing, output
is inhibited when the pacemaker senses
intrinsic activity.
 This minimizes competition between the
paced rhythm and the intrinsic activity of the
heart.
Why are patient’s in an asynchronus pacing
mode in OT?
 To change to demand mode: turn
sensitivity settings on (Atrial and/or
Ventricular) or use Dial-a-mode function

 To change from DDD to single chamber

demand pacing, set:
 A Output to OFF (DDD -> VVI)
 V Output to OFF (DDD -> AAI)

Works in reverse to return to dual pacing

 Viewing the Intrinsic Rhythm
 Avoid this in the early postoperative period
 PAH policy is not to use the PAUSE button.
 This button suspends all pacing and sensing
functions for up to ten seconds.
 Reduce the rate to look for loss of pacing
and sensing of patients own intrinsic rate.
 Why? -> Remember: HR x SV = CO
 Changing the Battery
 Battery indicator in the top left hand
corner of the upper screen appears when
battery needs changing.
 Once this appears, the device will operate
satisfactorily for a minimum of 24 hours at
or below a rate of 70, nominal outputs and
with the lower screen inactive.
 Best to change as soon as indicator appears
 It is not recommended to replace the
battery while the device is turned on.

 PAH Guideline is to set up another pacing

box with new battery (9V) and change
over pacing cables to the new box.
 Checking Output Threshold/s
 Output/stimulation threshold is the
least amount of current required to
elicit cell depolarisation.
 Not routinely performed in the first 12
hours postoperatively unless there are
problems with pacing (Why??)
 Output threshold can be affected by:
 faulty connections/leads
 flattening batteries
 location of electrode
 cell status

 Excessively high output can cause oedema

at the contact site in the myocardium
leading to tissue damage.
Why is this more of a problem with transvenous
pacing than epicardial?
Output Threshold Test Procedure:
Atrial & Ventricular settings need to be assessed separately
1. Patient connected to temporary pacemaker
and ECG monitored
2. Set pacing rate 10 above the intrinsic rate of
patient
3. This adjustment ensures pacing. The pace
indicator flashes.
4. Decrease output: turn the output dial slowly
counterclockwise until ECG shows loss of
capture.
5. Pace and sense indicators flash intermittently.
6. Increase output: turn the output dial slowly
clockwise until ECG shows consistent
capture.
7. The pace indicator flashes continuously, the
sense indicator stops flashing. This value is
the stimulation threshold.
8. Set output to a value 3 times greater than
the stimulation threshold value. Output
setting should not be less than 10mA.
9. Return pacing rate to previous value.
Checking Sensitivity Threshold/s
 Sensitivity setting determines the ability of
the pacemaker to recognize an intrinsic
impulse
 Sensitivity threshold is the lowest
sensitivity (highest mV) setting
required to consistently sense patient’s
intrinsic activity.
Sensitivity Threshold Test Procedure:
Atrial & Ventricular settings need to be assessed separately

1. Patient connected to temporary

pacemaker and ECG monitoring
2. Set PACING RATE 10 below the intrinsic
rate of patient to a minimum of 40. This
adjustment ensures non-pacing. The
sense indicator flashes.
3. Assess patient has an adequate
intrinsic rate and that blood
pressure is not compromised. If BP
compromised procedure is not done.
4. Adjust output setting to minimum – (0.1mA)
This adjustment avoids pacemaker competition with
intrinsic rhythm during the threshold test as capture
is unlikely at such a low output setting.

5. Press the menu key until menu 1 is displayed -

press the select key to highlight either Atrial or Ventricular
sensitivity

6. Decrease sensitivity: slowly turn the menu

parameter dial to increase the mV value until PACE
indicator flashes continuously.
The sense indicator stops flashing. The pace indicator
flashes continuously, but capture is not likely because
the output value is at minimum.
7. Increase sensitivity: slowly turn the menu
parameter dial to decrease the mV value until
the sense indicator flashes consistently
and the pace indicator stops flashing.
This value is the sensing threshold
7. Set sensitivity to half the threshold value
(eg. If threshold value = 5.0mV, set sensitivity
to 2.5mV this provides a 2:1 safety margin).
8. Restore pacing rate and output settings (A or
V) to previous values.
RETURN TO SESSION LIST
Troubleshooting
Pacing Problems
What is the problem here and would
you do if this happened?
 Problem: Failure to Capture
Actions:
 Increase ventricular output

 Check connections and battery

 Commence CPR if necessary

 Myocardium may not be viable

If this happens with transvenous pacing -

turn patient onto left side
What would you do if this happened?
Also, what mode is the pacemaker likely to be in?
 Problem: Failure to Sense
Actions:
 Increase sensitivity setting: decrease mV to
make the pacemaker more sensitive to the
patient’s own rhythm
 Change to DDD mode if currently in DOO

 Check/change battery – sensing function can

often be first to go if battery power is low
 If problem continues assess adequacy of
intrinsic rhythm and decrease rate or
discontinue pacing
What is the problem here and what
would you do if this happened?
 Problem: Over-sensing
Actions:
 Ensure connections are tight and secure
 Observe sensing light. If sense light is flashing
where there is no intrinsic QRS complex, decrease
ventricular sensitivity
 If inappropriate sensing continues without adequate
underlying rhythm - change to asynchronous mode
 Remove/treat potential causes of artifact (eg.
shivering, electrical interference)
How is this patient feeling at the
moment?!
Problem: Failure to Pace

Actions:
 Check all connections from patient, pacing

cable and pacemaker

 Check/change battery

 Commence CPR if necessary

 Check for loose / broken wires

RETURN TO SESSION LIST