1. 1. Does it Pace?
1.1. Threshold
1.1.1. Output measured in Amplitude (Volts) and duration (Pulse width measured in mS)
1.1.2. Shoot for at least a doubling of measured threshold. A bit more in dependant patients.
1.1.3. May make exceptions if Pacemaker has Beat to Beat back up.
2. 2. Does it sense?
2.1. Measured in mV.
2.2. Adjusting sensitivity is non-intuitive. Raise sensitivity by lowering the number and vice versa (think of paradigm of raising or lowering the fence - pacemaker sees all activity that is over the fence)
2.3. Oversensing can result in non-pacing (really a bad idea in dependant patients). Undersensing results in inappropriate pacing and potentially R on T (a bad thing particularly if there is underlying cardiomyopathy, but probably better than Oversensing in most situations.
3. 3. Are the leads OK?
3.1. Polarity optimized
3.2. Impedance
3.3. Placement
3.3.1. LBBB pattern in RV pacers.
3.3.2. Migration?
4. 4. Is the battery OK?
5. 5. Is programming optimized
5.1. Strategies to maximize clinical function
5.1.1. Rate responsiveness
5.2. Strategies to reduce pacing
5.2.1. Rate adjustments
5.2.1.1. Hysteresis
5.2.1.2. Night mode
5.2.2. Optimize AV delay
5.3. Other strategies to prolong battery life
5.3.1. Accepting smaller safety margins
5.3.2. Turning off monitoring functions
5.4. Misc.
5.4.1. Unipolar pacing is preferred by many when tolerated as it optimizes recognition of paced beats on surface ECG
6. 6. Are there arrhythmias?
6.1. Supraventricular
6.1.1. Burden of A fib
6.2. Ventricular
6.3. Sudden relative Brady
7. 8. Weird and Wonderful
7.1. Unusual problems
7.2. What you can learn about the physiology of your patient "You can see a lot just by looking" - Y Berra
7.2.1. The value of temporal data
8. 7. Pacemaker induced complications
8.1. Infection at site of pacemaker. Routine follow up should always include a look at the pace site (which can break down years after implant). Patients should be taught to call if site becomes red.
8.2. Pacemaker syndrome
8.3. Pacemaker mediated tachycardia
8.3.1. Short term solutions
8.3.1.1. Magnet
8.3.1.2. VVI
8.3.2. Long term solutions
8.3.2.1. Increase PVARP
8.4. 5 conditions in which PMT can occur
8.4.1. 1.
8.4.2. 2.
8.4.3. 3.
8.4.4. 4.
8.4.5. 5.