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Pacemaker Follow Up by Mind Map: Pacemaker Follow Up
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Pacemaker Follow Up

1. Does it Pace?

Threshold

Output measured in Amplitude (Volts) and duration (Pulse width measured in mS)

Shoot for at least a doubling of measured threshold. A bit more in dependant patients.

May make exceptions if Pacemaker has Beat to Beat back up.

2. Does it sense?

Measured in mV.

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)

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. Are the leads OK?

Polarity optimized

Impedance

Placement

LBBB pattern in RV pacers.

Migration?

4. Is the battery OK?

5. Is programming optimized

Battery Function (short term / long term) Arrhthmia detection  

Strategies to maximize clinical function

Rate responsiveness

Strategies to reduce pacing

Rate adjustments, Hysteresis, Night mode

Optimize AV delay

Other strategies to prolong battery life

Accepting smaller safety margins

Turning off monitoring functions

Misc.

Unipolar pacing is preferred by many when tolerated as it optimizes recognition of paced beats on surface ECG

6. Are there arrhythmias?

Supraventricular

Burden of A fib

Ventricular

Sudden relative Brady

8. Weird and Wonderful

Unusual problems

What you can learn about the physiology of your patient "You can see a lot just by looking" - Y Berra

The value of temporal data

7. Pacemaker induced complications

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.

Pacemaker syndrome

Pacemaker mediated tachycardia

Short term solutions, Magnet, VVI

Long term solutions, Increase PVARP

5 conditions in which PMT can occur

1.

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