Indications

Front 1

Conduction System Components

Back 1

SA Node, Bachman's Bundle, AV Node, HIS Bundle, Left BB, RBB, Posterior Fascicle of LBB, Anterior Fascicle of LBB, RBB
and Purkinje Fibers

Front 2

AV Node Slows Conduction - Why?

Back 2

1. It augments filling of ventricles for atrial kick.
2. As a protective measure for the ventricles

Front 3

Normal Intervals

Back 3

PR = 120-200 mS
QRS = 60-120 mS
QT = 360-440 mS

Front 4

Causes of Conduction Problems

Back 4

1. aging
2. Coronary disease
3. Open Heart Surgery
4. Myocarditus

Front 5

Bradycardia Symptoms

Back 5

1. Syncope or pre-syncope
2. Dizziness
3. Congestive heart failure
4. Mental Confusion
5. Palpitations
6. Shortness of Breath - Dyspnea
7. Exercise Intolerance

Front 6

Sinus Node Dysfunction or Sick Sinus Syndrome - Characteristics

Back 6

1. Sinus Bradycardia
2. Sinus Arrest
3. SA Block
4. Brady-Tachy Syndrome
5. Chronotropic Incompetence

Front 7

Sinus Bradycardia

Back 7

1. Persistent Slow rate from SA Node
2. 59 bpm and less
3. PR interval of 180 ms

Front 8

Sinus Arrest

Back 8

= failure of SA node to discharge resulting in the absence of atrial depolarization and periods of ventricular asystole

*** pauses are of different lengths

Front 9

SA Exit Block

Back 9

= transient blockage of impulses from the SA Node

*** Sinus node fires and stays in rhythm

Front 10

Brady - Tachy Syndrome

Back 10

=intermittent episodes of slow and fast rates from the SA Node or atria.

1. See these the most for devices
2. May put them on meds to slow the tachycardia.... but may need device if it slows too much.
3. If not on therapeutic meds this is OK but if on digitalis you need to be careful or change med

Front 11

Chronotropic Incompetence

Back 11

= heart rate doesn't match the workload
*** usually can't get the heart rate to go above 100 bpm

Front 12

Pacemaker Indications

Back 12

Class I = everyone agrees & there is evidence to get a device
Class II = Divergence of opinon
Class III = not an approved indication

Front 13

Sinus Node Indications

Back 13

Class I = sinus node dysfunction with documented symptomatic sinus bradycardia

Class II = symptomatic patients with sinus node dysfunction and with no clear association between symptoms and bradycardia

Class III = asymptomatic sinus node dysfunction

Front 14

Pacemaker Tests to Obtain

Back 14

Event Monitor = 2-3 weeks
Holter Test = 24 hours
Exercise = repeat the activity to figure out problem

Front 15

AV Block Indications -Class I

Back 15

Class I =
A. 3rd degree AV block associated with:
1. symptomatic bradycardia
2. Documented periods of asystole of > or = 3 seconds
3. Escape rate is < 40 bpm in awake, symptom free patients
4. Post AV Junction ablation
5. Post operative AV Block not expected to resolve

B. 2nd Degree AV Block regardless of type or site of block, with associated symptomatic bradycardia

Front 16

AV Block Indications Class II

Back 16

1. Chronic Heart Block with ventricular rate > 40 bpm
2. Type II 2nd degree AV Block
3. Type I 2nd degree AV block within the HIS Purkinje system
4. 1st degree AV block with pacemaker syndrome symptoms

Front 17

Neuromuscular Diseases that can cause heart block

Back 17

1. Muscular Dystrophy
2. Kearns -Sayre Syndrome
3. Limp-Girdle Distrophy
4. Peroneal Muscular Atrophy

Front 18

High Grade AV Block

Back 18

The lower the block the more significant it is.

Eschemia - blood plumbing problems and it can get bad enough that you die

Front 19

Heart Blocks progression?

Back 19

1. 1st degree heart to heart block does not happen

2. Mobitz II to heart block does occur

Front 20

Kearns-Sayre Syndrome

Back 20

Rare genetic abnormality classified as mitochondrial cytopathy with a disturbance of mitochondrial DNA which codes for proteins required for the respiratory chain reaction

Front 21

Bifascicular and Trifascicular Block Indications

Back 21

Class I =
a. Intermittent 3rd degree AV Block
b. Type II 2nd degree AV block

Class II =
a. Syncope not proved to be due to AV block when other causes have been excluded, specifically VT
b. Prolonged HV interval (in AV node)
c. Pacing Induced infra HIS block that is not physiological

Front 22

Hypersensitive Carotid Sinus Syndrome

Back 22

Right side is more sensitive than left

Front 23

Vasovagal Syncope -

Back 23

vasovagal syncope is usually in young patients and is difficult to get rid of all of their symptoms. Results in drop in heart rate and blood pressure. May need to set up hysteresis rate and use only a few times per year. Can be triggered by fear, anxiety, physical pain and prolonged standing.

Front 24

Bifascicular Block

Back 24

1. Right bundle branch block and left posterior hemiblock

2. Right Bundle Branch Block and left anterior hemiblock

3. Complete left bundle branch block

Front 25

Difference between Bifascicular and Bilateral Block

Back 25

Bilateral has one block on each side and Bifascicular can have 2 blocks on one side

Front 26

Trifascicular Block

Back 26

Complete block in the right bundle branch and complete or incomplete block in both divisions of the left bundle branch

Front 27

Lenegre or LEV Disease

Back 27

An idiopathic progressive cardiac conduction disease characterized by age related conduction disease that can lead to AV block and a pacemaker

Front 28

Bifascicular and Trifascicular Block Indications

Back 28

Class I
a. Intermittent 3rd degree AV block
b. Type II 2nd degree AV block

Class II
a. Syncope not proved due to AV block when VT has been excluded
b. Prolonged HV interval

Front 29

AV Block Associated with MI Indications

Back 29

Class I
a. Persistent 2nd degree & 3rd degree AV block

b. Persistent 2nd degree block in the HIS-Purkinje system or 3rd degree block within or below the HIS-Purkinje system

Class II
a. Persistent 2nd or 3rd degree block at the AV node level

Front 30

Hypertrophic Cardiomyopathy

Back 30

1. Most common cause of death in young people < 25 and 36% of athletic deaths
2. LV hypertrophy > 30 mm wall thickness - responsible for 40% of sudden cardiac death at 20 years

3. Use Echo test to diagnose

4. Complications - VT, AF, Stroke, SCD

5. Only patients it makes sense in to pace from the RV Apex because it gives you pure capture and more filling time. You want longest short AV time that gives you pure capture

Front 31

HOCM = hypertrophic obstructive myopathy

Back 31

1. Is an obstructive indication for a pacemaker

1a. 1 in 500 to 1 in 1000 have it

2. also shown to improve hemodynamics in mid cavity obstructive cardiomyopathies

Front 32

Stokes Adams Syndrome

Back 32

Ventricular Bradycardia with syncope and they do get a pacemaker

Front 33

Pacemakers in Children

Back 33

1. If > 15 kilograms then epicardial

2. If < 15 kilograms then endocardial

Front 34

Long QT -what happens

Back 34

a. makes one prone to Torsades do PointesT
b. Therapy options - B blockers, pacing at faster rate
c. Need ICD

Front 35

Pacing for Heart Failure

Back 35

Need wide QRS and LVEF to obtain device

Front 36

Orthotopic vs. Heterotopic Heart procedure

Back 36

1. Orthotopic - entire heart is removed

2. Heterotopic - only part of the heart is removed

Front 37

Vasodepressor Syncope

Back 37

1. Patients have decreased venous return and therefore a rigorous contraction occurs. Treat with saline and most folks never get a device

Front 38

CSS and VVS Indications

Back 38

1. Class I: recurrent syncope

good idea to do a doppler sonogram to reduce the risk of stroke before doing carotid sinus message

Front 39

Sleep Apnea

Back 39

1. Not an approved indication
2. Higher in heart failure
3. 4 X more likely for AFIB
4. 3 X more likely for VF