How to follow up a patient with a pacemaker?

Yasmeen KamalTanta Rhythm Group

1 -Remote monitoring

•Trans Telephonic

•Via Internet

2-PaceMaker Clinics

Remember You are checking on a patient Not a software

Remember Samanatha?

Recommendations for Permanent Pacemaker Services

According to Canadian recommendations

2011

Resource Requirements for Pacemaker Clinics

Human Resources:

Medical Director or Most Responsible Physician (MRP)

Pacemaker Follow-up Physicians

Registered Nurses and Allied Health Professionals

Documentation and Database Requirements

Equipment Resources

EchoCardiography , Exercise ECG , Tilt table test , up to EP unit

Content of Follow-up

Four Categories of Pacemaker-Monitoring Goals according to:

HRS/EHRA Expert Consensus on the Monitoring of Cardiovascular Implantable Electronic Devices (CIEDs) 2008

1-Patient-related

2-PaceMaker related

3-Disease related

4-Communication related

History and physical examination

Don’t forget to check on Wound

Every Visit

Be aware of: Late device infection!!!!

History of cerebro vascular insult .. AF??

Chest pain

HF symptoms

Dizziness or syncope

edema or pain on the pacemaker sided limb

Palpitation

others

12 Lead ECG

The Pacemaker ECGs are illustrated in separate lecture

Note that : The ECG is Your best friend

You can know a lot about the pacemaker functions only from the ECG

Cherchez Le “P”

Chest X-ray

•Lead position

•Lead Fracture

•Other associations

Apply a Magnet

•Asynchronous pacing on applying the magnet at magnet rate ”VOO , DOO”

•The magnet rate usually differs from the ususal programmed rate•According to the manufacturer

•Reflects the status of the battery

•Some devices allow the magnet response to be programmed on & off

USE The Programmer

Match the programmer head with the pacemaker and wait for interrogation

Start interrogation

Place the programmer head over the device

Medtronic

Boston

Saint JudeBitotronik

1-capture Threshold voltage measurement“at certain pulse width”

Remember the strength duration curve

Make sure that the safety margin is adequate

DON’T RELY ON EGM

2-Sensing thresholdMeasure intrinsic P and R wave endocardial signals

Adjust sensitivity

3-Lead impedance

Compare Results with previous data

Check programmed data “ output , sensitivity , hysteresis , base rate ,

UTR , PVARP , AMS , autocapture”

That was the measured data

Take a look on the memorized data

Remote monitoring

Take Home messages

1. You are a cardiologist and you have patients at the follow-up clinic , not smart phones

2. Collect and compare data

3. The 12 Lead ECG remains your best friend

4. Don’t trust the EGM alone

5. Devices are smart but you are smarter

Lots of data you obtain about patients lives from their devices

Does it feel good to share your life details with somebody?

Thank you