Cardiac Pacing, Defibrillation and Resynchronization: A Clinical Approach

Cover
Title Page
Copyright Page
Contents
Contributors
Preface
Chapter 1 Pacing and Defibrillation: Clinically Relevant Basics for Practice
Anatomy and physiology of the cardiac conduction system
Electrophysiology of myocardial stimulation
Pacing basics
Stimulation threshold
Variations in stimulation threshold
Clinical considerations when considering threshold
Sensing
Lead design
Bipolar and unipolar pacing and sensing
Left ventricular and His bundle pacing leads
Epicardial leads
Defibrillator leads – special considerations
Leadless pacemakers
Pulse generators
Pacemaker nomenclature
Essentials of defibrillation
Critical mass
Upper limit of vulnerability
Progressive depolarization
Virtual electrode depolarization
Electroporation as a mechanism for defibrillation
Defibrillation theory summary
The importance of waveform
Biphasic waveforms
Phase duration and tilt
Polarity and biphasic waveforms
Mechanism of improved efficacy with biphasic waveforms
Measuring shock dose
Measuring the efficacy of defibrillation
Threshold and dose–response curve
Relationship between defibrillation threshold and dose–response curve
Patient-specific defibrillation threshold and safety margin testing – clinical indications
Management of the patient who fails defibrillation testing
Upper limit of vulnerability to assess safety margin
Practical implications of defibrillator therapies
Drugs and defibrillators
Antitachycardia pacing
Summary
References
Chapter 2 Hemodynamics of Cardiac Pacing: Optimization and Programming to Enhance Cardiac Function
Cardiovascular physiology
Abnormal physiology
Basics of hemodynamic pacing
Chronotropic response
Atrioventricular dissociation and ventriculoatrial conduction
Atrioventricular synchrony
Rate-adaptive atrioventricular intervals
Atrioventricular optimization
Principles of echocardiographic atrioventricular optimization
Atrial mechanical function
Effect of pacing mode on morbidity and mortality
Pressure–volume optimization
Optimal ventricular pacing sites
Pacing in heart failure
Influence of pacing site
Mechanisms underlying the benefits of left ventricular and biventricular pacing
Left ventricular diastolic function
Atrioventricular optimization in cardiac resynchronization therapy
Ventricular timing optimization (ventriculo-ventricular optimization)
Optimizing site of pacing (left ventricular and/or right ventricular)
Electrical parameters for ventriculo-ventricular optimization
QRS vector fusion
Echocardiography for ventricular timing optimization
Clinical approaches to ventriculo‐ventricular optimization
Newer programming features to optimize hemodynamics via pacing
Other endpoints for optimization
Right ventricular function
Cardiac contractility modulation pacing
Ventricular rate regulation
Less common indications for pacing for hemodynamic improvement
Pacing in hypertrophic obstructive cardiomyopathy
Hemodynamic benefits of pacing in neurocardiogenic syndromes
Hemodynamic benefits of pacing in first-degree atrioventricular block
Conclusions
References
Chapter 3 Indications for Pacemakers, Implantable Cardioverter-Defibrillators, and Cardiac Resynchronization Therapy: Identifying Patients Who Benefit from Cardiac Rhythm Devices
Indications for permanent pacing
Atrioventricular block
Acute myocardial infarction
Chronic bifascicular and trifascicular block
Sinus node dysfunction
Neurally mediated reflex syncope
Tachyarrhythmias
Hypertrophic cardiomyopathy
Congestive heart failure
Pacing after cardiac transplantation
Indications for the implantable cardioverter‐defibrillator
Secondary prevention
Primary prevention
Coronary artery disease
Dilated cardiomyopathy
Long QT syndrome
Brugada syndrome and sudden unexplained death syndrome
Other channelopathies
Arrhythmogenic right ventricular dysplasia
Hypertrophic cardiomyopathy
Congenital heart disease
Wearable cardioverter-defibrillator therapy
Contraindications to implantable cardioverter-defibrillator therapy
Acknowledgement
References
Chapter 4 Choosing the Device Generator and Leads: Matching the Device with the Patient
Pacemaker selection
Symptomatic bradycardia
Pure sinus node dysfunction
Pure atrioventricular block
Neurocardiogenic syncope and carotid sinus hypersensitivity
Choosing specific programmable options
Choosing the rate-adaptive sensor
Choosing the lead or leads
Threshold reduction
Lead polarity
Electrode design
Lead conductor
Lead insulation
Lead diameter
Compatibility of lead and pulse generator
Epicardial leads
Resources for lead performance and survival data
Leadless pacemakers
Generator and lead selection in defibrillators
Lead design considerations for internal cardioverter-defibrillator leads
Programmable waveforms
Dual-chamber or single-chamber internal cardioverter-defibrillator?
Factors favoring single-chamber defibrillators
Factors favoring dual-chamber defibrillators
Specific device and lead features influencing selection
Conclusions
References
Chapter 5 Implanting and Extracting Cardiac Devices: Technique and Avoiding Complications
Implantation facility
Anesthesia
The pulse generator pocket
Venous approaches
Axillary (extrathoracic subclavian) approach
Subclavian approach
Cephalic approach
Jugular approach
Iliac vein approach
Ventricular lead placement
Coronary sinus lead placement
Coronary sinus cannulation
Coronary sinus venography
Securing permanent leads
Dual-chamber pulse generator implantation
Measurement of pacing and sensing thresholds
Determination of pacing threshold
Determination of sensing threshold
Epicardial systems
Hardware adaptations
Special considerations in pediatric patients
Device implantation after cardiac transplantation
Leadless pacemaker implantation
Selective conduction system pacing
Delivery tools
Subcutaneous implantable cardioverter-defibrillator implantation
Interventional techniques for device implantation procedures
Hospital stay after implantation
Pulse generator replacement
Postimplant order set
Homegoing instructions
Lead extraction
Indications for lead extraction
Facility requirements for lead extraction
Outcomes of lead extraction
Complications of lead extraction
Extraction techniques
References
Chapter 6 Implant-Related Complications: Relevant Anatomy and Approaches for Prevention
Inadvertent left ventricular lead placement
Lead dislodgment
Loose connector block connection
Pneumothorax
Lead perforation
Pericarditis
Pulse generator pocket hematoma
Pain
Arrhythmias
Extracardiac stimulation
Infection
Allergic reaction
Twiddler’s syndrome
Thrombosis
Battery depletion
Loss of circuit integrity from therapeutic radiation
Patients with conventional cardiac implantable electronic device undergoing magnetic resonance imaging
Abandoned and nonfunctioning, noninfected leads
Subclavian crush, lead fracture, and insulation defect
Pacemaker syndrome
Tricuspid regurgitation
Dyssynchrony and cardiomyopathy
Complications in specific devices
Magnetic resonance conditional devices
Cardiac resynchronization therapy device
Subcutaneous implantable cardioverter defibrillator
Leadless pacemaker
Acknowledgements
References
Chapter 7 Timing Cycles
Basic approach
Pacing modes
Atrial inhibited pacing
Single-chamber triggered-mode pacing
Rate-modulated pacing
Atrioventricular sequential, ventricular inhibited pacing (DVI)
Atrioventricular sequential, non-P-synchronous pacing with dual-chamber sensing (DDI)
Atrioventricular sequential, non-P-synchronous, rate-modulated pacing with dual-chamber sensing (DDIR)
Atrial synchronous (P-tracking/P-synchronous) pacing (VDD)
Dual-chamber pacing and sensing with inhibition and tracking (DDD)
Portions of pacemaker timing cycles
Atrioventricular interval
Comparison of atrial with ventricular-based timing
Dual-chamber rate-modulated pacemakers: effect on timing cycles
Mode switching
Avoiding atrial pace/sense competition
Timing components of ventricular avoidance pacing algorithms
Endless-loop tachycardia
Timing cycles with algorithms responding to sudden bradycardia
Timing cycles unique to biventricular pacing
Timing cycles in implantable cardioverter-defibrillators
Initial electrocardiographic interpretation
Response to magnet application
Single-chamber pacemakers
Dual-chamber pacemakers
Biventricular paced electrocardiogram: position, adequacy, and timing
Characteristic electrocardiographic patterns with specific lead locations
Timing intervals and the electrocardiogram
Atrioventricular interval programming
Electrocardiographic considerations in the patient not responding to cardiac resynchronization therapy
Conclusions
References
Chapter 8 Programming: Maximizing Benefit and Minimizing Morbidity Programming
Defibrillator programming
Implantable cardioverter-defibrillator sensing
Implantable cardioverter-defibrillator detection
Supraventricular tachycardia–ventricular tachycardia discriminators
Dual-chamber supraventricular tachycardia–ventricular tachycardia discriminators
Ventricular therapies
Atrial defibrillators: detection and therapies
Optimizing programming: general consideration
Optimizing programming: manufacturer-specific recommendations
Subcutaneous implantable defibrillator
Cardiac resynchronization programming
Algorithms to promote continuous tracking
Algorithms to manage premature ventricular complexes
Algorithms to manage atrial fibrillation
Device-based optimization for cardiac resynchronization
Conclusions
References
Chapter 9 Sensor Technology for Rate-Adaptive Pacing and Hemodynamic Optimization
Indications for rate-adaptive pacing
Sensors available for rate-adaptive pacing
Activity sensors
Minute ventilation sensors
SonR sensor (previously called peak endocardial acceleration sensor)
Right ventricular impedance-based sensor
Stimulus-T or QT, sensing pacemaker
Temperature-sensing rate-adaptive pacemakers
Other sensors
Dual-sensor rate-adaptive pacing
Sensor applications for hemodynamic management
Programming
Programmable parameters
Rate-adaptive pacing with cardiac resynchronization devices
Programming atrioventricular and interventricular optimization
Future of rate-adaptive sensors
References
Chapter 10 Troubleshooting
Fundamentals
Issues common to all cardiovascular implantable electronic devices
History specific to troubleshooting implantable cardioverter-defibrillator shocks
Basics of troubleshooting sensing
Electrogram sources
Event markers, undersensing, and oversensing
Stored versus real-time electrograms
Near-field versus far-field electrograms
Pacemaker troubleshooting
Absence of expected pacing
Pacing with an altered rate or escape interval
Failure to capture
Other pacemaker issues
Implantable cardioverter-defibrillator troubleshooting
Troubleshooting antitachycardia therapy
Ventricular oversensing: diagnosis and management
Diagnosis of implantable cardioverter-defibrillator lead failure
Approach to the patient with frequent shocks
Unsuccessful shocks
Failure to deliver or delayed therapy
Troubleshooting the subcutaneous implantable cardioverter-defibrillator
Troubleshooting subcutaneous implantable cardioverter-defibrillator oversensing
Troubleshooting cardiac resynchronization devices
Resynchronization of <90–95% of R-R intervals
Troubleshooting other problems in cardiac resynchronization therapy systems
References
Chapter 11 Radiography of Implantable Devices
Introduction
Pulse generators
Leads
Pacemaker leads
Transvenous atrial leads
Transvenous ventricular leads
Epicardial leads
Implantable cardioverter-defibrillator leads
Epicardial implantable cardioverter-defibrillator leads
Transvenous implantable cardioverter-defibrillator leads
Coronary venous leads
Miscellaneous considerations
Conclusions
References
Chapter 12 Electromagnetic Interference: Sources, Recognition, and Management
Pacemaker responses to noise
Asynchronous pacing
Mode resetting (power-on reset, or electrical reset)
Environmental electromagnetic interference
Clinical advice
Hacking
References
Chapter 13 Follow-up
Requirements for a device follow-up clinic
Space
Personnel
Equipment
Pacemaker follow-up
Trans-telephonic monitoring
Equipment
Trans-telephonic monitoring sequence
Remote monitoring and integration
Pacemaker clinic follow-up visit
Leadless intracardiac pacing system
Implantable cardioverter-defibrillator follow-up
Assessment of the patient’s clinical status
Pulse generator assessment
Capacitor status
Assessing lead function
Defibrillation efficacy assessment
Medications
Strategies to minimize shocks
Subcutaneous implantable cardioverter-defibrillators
Cardiac resynchronization therapy follow-up specifics
Patients’ concerns during follow-up
Medical advisories and recalls
Lifestyle and personal concerns
Psychologic issues encountered following device implantation
Withdrawal of device support
Conclusions
References
Index
EULA