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Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy E-Book

Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy E-Book

Kenneth A. Ellenbogen | Bruce L. Wilkoff | G. Neal Kay | Chu Pak Lau | Angelo Auricchio

(2016)

Additional Information

Book Details

Abstract

Your must-have bench reference for cardiac electrophysiology is now better than ever! This globally recognized gold standard text provides a complete overview of clinical EP, with in-depth, expert information that helps you deliver superior clinical outcomes. In this updated 5th Edition, you’ll find all-new material on devices, techniques, trials, and much more – all designed to help you strengthen your skills in this fast-changing area and stay on the cutting edge of today’s most successful cardiac EP techniques.

  • Expert guidance from world authorities who contribute fresh perspectives on the challenging clinical area of cardiac electrophysiology.
  • New focus on clinical relevance throughout, with reorganized content and 15 new chapters.
  • New coverage of balloons, snares, venoplasty, spinal and neural stimulation, subcutaneous ICDs and leadless pacing, non-CS lead implantation, His bundle pacing, and much more.
  • New sections on cardiac anatomy and physiology and imaging of the heart, a new chapter covering radiography of devices, and thought-provoking new information on the basic science of device implantation.
  • State-of-the-art guidance on pacing for spinal and neural stimulation, computer simulation and modeling, biological pacemakers, perioperative and pre-procedural management of device patients, and much more.

Table of Contents

Section Title Page Action Price
Front Cover cover
Inside Front Cover ifc1
Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy i
Copyright Page ii
Dedication iii
Contributors iv
Preface ix
Table Of Contents xi
Video Contents xiii
1 Basic Principles 1
1 Cardiac Anatomy and Pathology 3
The Heart in the Chest 3
Relationships of Cardiac Chambers 3
The Right Atrium 4
Right Atrial Appendage, Terminal Crest, and Sinus Node 4
Eustachian Valve, Vestibule, Triangle of Koch, and Atrioventricular Node 5
The Venous Component, Orifices of Caval Veins, and Coronary Sinus 7
The Anterior Wall and the Atrial Septum 7
The Right Ventricle 8
The Left Atrium 9
The Left Ventricle 10
The Cardiac Veins 11
References 13
2 Imaging of Cardiac Anatomy 15
Imaging Techniques in Cardiology 15
Fluoroscopic Anatomy 15
The Position of the Heart 15
Anatomy 15
Imaging Technique 16
The Esophagus 16
Anatomy 16
Imaging Techniques 16
The Right Atrium 17
Anatomy 17
Imaging Techniques 17
General Concepts 17
Terminal Crest 19
2 Engineering and Construction of Devices and Leads 249
8 Power Sources and Capacitors for Pacemakers and Implantable Cardioverter-Defibrillators 251
Introduction 251
Batteries 251
Basic Function and Electrochemistry of Batteries 251
Energy Storage in Batteries 251
Chemical Reactions 251
Major Components of Batteries 251
Anode and Cathode 251
Electrolyte 252
Separator 252
Current Collector 252
Sealing of Batteries 252
Classification of Batteries 252
Primary Batteries 252
Secondary Batteries 252
Functional Characteristics of Batteries 252
Capacity 252
Energy and Energy Density 253
Stoichiometry and Cell Balance 253
Cell Voltage and Current 253
Internal Resistance and Impedance 253
Nonideal Battery Behavior 253
Polarization 253
Self-Discharge and Other Parasitic Reactions 253
Use of Batteries in Implantable Cardiac Rhythm Management Devices 254
Implantable Battery Design Requirements 254
Power Requirements 254
Average Versus Instantaneous Current Drain 254
Shape, Size, and Mass Constraints 254
Relationship Between Size, Energy Density, and Current Drain 255
The Battery and Longevity of the Pulse Generator 255
Effect of Pulse Width on Pacing Current 255
Effect of Pulse Amplitude on Pacing Current 255
Effect of Lead Impedance on Pacing Current 256
Summary of Programming Effects on Longevity of Bradycardia Pulse Generators 256
Considerations for Longevity of ICDs 256
Battery End-of-Service Indication 256
Elective Replacement Indicator 256
Methods for Monitoring State of Battery Discharge 256
Battery Voltage 256
Battery Impedance 257
Consumed Charge 257
Blended Methods 257
False RRT Triggering 257
Clinical Indicators of the Battery Replacement Time 257
Battery Chemistries Used in Pacemakers 258
The Lithium/Iodine Battery 258
Lithium/Iodine Cell Structure 258
Discharge Curve for the Lithium/Iodine Battery 258
Effects of Current Drain on Deliverable Capacity of Lithium/Iodine Cells 258
The Lithium/Carbon Monofluoride Battery 258
The Lithium/Hybrid Cathode Battery 258
The Lithium/Manganese Dioxide Battery 259
Battery Chemistries Used in Defibrillators 259
Comparison of Pacemaker and Defibrillator Batteries 259
Types of Batteries Used in ICDs 260
Li/SVO Batteries 260
Charge Time-Optimized Li/SVO ICD Batteries 261
Lithium/Manganese Dioxide Batteries 261
Silver-Vanadium Oxide-Carbon Monofluoride (Layered Dual Cathode and Hybrid Cathode) 262
Safety 262
Emerging Power Sources 262
Rechargeable Lithium-Ion Batteries 262
Principles of Operation 263
Method of Recharge 263
End-of-Service Life Indication 263
Miniature Batteries for Leadless Devices 263
Energy Harvesting 264
Predictive Models and Accelerated Test Methods 264
Capacitors 264
Basic Function of Capacitors 264
ICD Device Requirements Important for Capacitors 265
ICD Capacitor Types 265
Anode Materials in Current ICD Capacitors 265
Cathode Materials in Current ICD Capacitors 266
Parasitic Reactions in Current ICD Capacitors 266
Energy Delivery 266
Energy Density 266
ICD Capacitor Construction 267
Stacked-Plate Aluminum Electrolytic Construction 267
Tantalum Electrolytic Capacitor Construction 267
Long-Term Degradation of Uncharged Capacitors: Deformation 267
Future Developments 268
Effects of Batteries and Capacitors on Defibrillation Performance 268
Energy Losses in Defibrillators 268
Clinical Implications of Battery and Capacitor Design on Defibrillation Therapy 268
References 269
9 Lead Connection Systems and Standards for Cardiac Implantable Electronic Devices 270
Early Years: Clinical Confusion and Need for Standardized Connection Systems 270
Unipolar Pacemaker Connection Systems 270
Bipolar Pacemaker Connection Systems 270
Advent of Adaptors: A Necessary Evil 271
Initial Voluntary Connector Standards 272
Voluntary Standard 1 272
IS-1 Pacing Lead Connector Standard 273
Early ICD Lead Connectors 274
DF-1 Standard 274
DF4/IS4 Standard 275
DF4 and IS4 Connector Labeling and Use 275
DF4 and IS4 Device Connector Cavity Design 277
DF4 and IS4 Clinical Advantages and Disadvantages 278
DF4 and IS4 Preclinical Testing and Subsequent Regulatory and Clinical Approach 279
DF4/IS4 Connector System Patient Testing at Implant 279
Conclusions 279
References 280
10 Sensors for Implantable Cardiac Pacing Devices 281
Basis of Rate-Adaptive Pacing 281
Exercise Response in Heart Failure 281
Heart Rate Response for Nonexercise Needs 281
Ideal Sensor Characteristics 281
Classification of Sensors and Algorithms 281
Technical Classification 282
Activity Sensing 284
Principle of Activity Sensing 284
Technical Aspects of Activity Sensors 285
Algorithms 287
Current Activity-Sensing Devices 287
Medtronic Activity-Sensing Devices 287
St. Jude Medical Activity-Sensing Devices 289
Boston Scientific Activity-Sensing Devices 289
Biotronik Activity-Sensing Devices 289
Sorin Activity Sensors 290
Clinical Experience with Activity Sensors 290
Limitations of Activity-Sensing Devices 291
Minute Ventilation Sensing 291
Physiologic Principle 291
Relationship Between Heart Rate and Respiratory Parameters During Exercise 291
Anaerobic Threshold 292
Effect of Pulmonary Disease and Congestive Heart Failure on Minute Ventilation Sensing 292
The Minute Volume Sensor 292
Algorithm 293
Current Minute Ventilation-Sensing Devices 293
Boston Scientific Minute Ventilation-Sensing Devices 293
Sorin Minute Ventilation-Sensing Devices 294
Sleep Apnea Monitoring 294
Clinical Experience of Minute Ventilation-Sensing Pacemakers 294
Limitations of Minute Ventilation Sensing 294
Unipolar Ventricular Impedance: Closed-Loop Stimulation Sensor 295
Sensor and Algorithm 295
Clinical Experience of Closed-Loop Stimulation Pacemakers 296
Advantages and Limitations 298
Special Lead Sensors 298
Peak Endocardial Acceleration 298
Sensor and Algorithm 298
Clinical Use of Peak Endocardial Acceleration Sensor 298
Central Venous Temperature 299
Variations of Central Venous Temperature Changes on Exercise and Other Physiologic Conditions 299
Sensor and Algorithm 300
Clinical Performance 300
Advantages and Limitations 300
3 Established and Emerging Clinical Concepts 373
13 Pacing for Sinus Node Disease 375
Pathophysiology of Sinus Node Disease 375
Cellular Electrophysiology of Sinus Node Disease 375
Clinical Electrophysiology of Sinus Node Disease 375
Clinical Presentation 378
Diagnosis of Sinus Node Disease 378
Natural History 378
Clinical Outcomes in Sinus Node Disease 378
Pacing and Survival in Sinus Node Disease 378
Pacing and Atrial Fibrillation in Sinus Node Disease 379
Atrial Fibrillation Detection in Pacemakers 380
Atrial Based Versus Ventricular Pacing for Prevention of Atrial Fibrillation 382
Atrial Pacing Versus Dual-Chamber Pacing for Prevention of Atrial Fibrillation 383
Pacing Algorithms for Prevention of Atrial Fibrillation 383
Are There Subgroups Who Benefit From Atrial Fibrillation Prevention Pacing Therapies? 384
Pacing Algorithms for Termination of Atrial Fibrillation 384
Site-Specific Atrial Pacing for Prevention of Atrial Fibrillation 386
Pacing and Stroke in Sinus Node Disease 386
Relationship Between Stroke Risk and Atrial Fibrillation Burden/Atrial Fibrillation Duration 388
Pacing and Pacemaker Syndrome in Sinus Node Disease 388
Pacing and Heart Failure in Sinus Node Disease 389
Pacing and Quality of Life in Sinus Node Disease 390
Chronotropic Incompetence 390
Potential Detrimental Effects of Ventricular Pacing in Sinus Node Disease 390
Ventricular Pacing and Risk of Atrial Fibrillation 390
Right Ventricular Pacing and Heart Failure Risk 390
Algorithms to Minimize Right Ventricular Pacing 391
Dynamic/Adaptive Atrioventricular Intervals 391
Mode Switching From AAI to DDD 391
Clinical Outcomes With Algorithms to Minimize Right Ventricular Pacing 392
Is One Mode for Minimizing Ventricular Pacing Superior? 394
Complications/Clinical Nuances of Algorithms to Minimize Ventricular Pacing 394
Treatment of Sinus Node Disease 394
Pacing Modalities in Sinus Node Disease 394
Chronotropic Incompetence and Rate-Adaptive Pacing 395
Alternative Ventricular Pacing Sites 396
Biologic Pacemakers 396
References 396
14 Atrioventricular Conduction System Disease 399
Anatomy 399
Anatomy of the His Bundle 399
Diagnosis of Atrioventricular Conduction Disturbances 399
Electrocardiography 399
Electrophysiologic Study 405
Identifying Patients at Risk for Atrioventricular Block 406
Classification, Epidemiology, and Natural History of Atrioventricular Conduction Disturbances 407
First-Degree Atrioventricular Block 408
Second-Degree Atrioventricular Block 408
Complete Heart Block 409
Paroxysmal Atrioventricular Block 409
Idiopathic Paroxysmal Atrioventricular Block 409
Bundle Branch Block 409
Congenital Atrioventricular Block 410
Inherited Conduction System Diseases 410
Cardiac Sodium Channel and Conduction Disorders 411
Acquired Causes of Atrioventricular Block 413
Indications for Permanent Pacing in Chronic Atrioventricular Block 418
Acute Myocardial Infarction 419
Atrioventricular Block Without Bundle Branch Block 420
Atrioventricular Block with Bundle Branch Block 420
Impact of Reperfusion 421
Bundle Branch Block after Recovery 423
Electrophysiologic Studies in Atrioventricular Block and Bundle Branch Block 423
Indications for Pacing 423
Temporary Pacing 423
Permanent Pacing 424
Selection of Pacing Mode in Atrioventricular Block 425
VDD(R) Pacing 427
Optimal Atrioventricular Interval Programming 428
Site-Specific Ventricular Pacing in Atrioventricular Block 430
Biventricular Pacing 434
Permanent His Bundle Pacing 434
Criteria for His Bundle Pacing 436
Pacing Outcomes 437
His Bundle Pacing in Atrioventricular Block 439
His Bundle Pacing in Bundle Branch Block 441
Implantation Site of Permanent His Bundle Pacing Lead 441
Effect of His Bundle Pacing on Cardiac Function 441
Special Considerations with His Bundle Pacing 442
Future Directions in His Bundle Pacing 444
Automatic Capture Verification and Pacing Output Management 446
Summary 449
Conclusion 450
References 450
15 Pacing in Reflex (Neurally-Mediated) Syncopes 454
The Clinical Spectrum of Reflex Syncopes 454
Vasovagal Syncope (Typical and Atypical Forms) 454
Clinical Perspective 454
Epidemiology 454
Conservative Therapy 455
Lifestyle Measures 455
Physical Counterpressure Maneuvers 455
Tilt Training (Standing Training) 455
Additional Treatments 456
Pharmacologic Therapy 456
Rationale and Evidence for Cardiac Pacing Therapy 456
Evidence From the Trials on Patients With Tilt-Induced Vasovagal Syncope 456
Evidence From the Trials in Patients With Suspected or Certain Vasovagal (Reflex) Syncope and Electrocardiogram-Documented Asystole 456
Carotid Sinus Syndrome 458
Clinical Perspective 458
Diagnosis With Carotid Sinus Massage 458
Rationale and Evidences for Cardiac Pacing Therapy 458
Evidence From the Trials in Patients With Carotid Sinus Syndrome 458
Adenosine-Sensitive Syncope 459
Reflex Syncopes: Indications for Pacing 461
Reflex Syncopes: Choice of Pacing Mode 462
References 462
16 Defibrillation Therapy 464
Implantable Cardioverter-Defibrillators 464
Early Clinical Trials with Implantable Cardioverter-Defibrillators in Cardiac Arrest Survivors 464
Clinical Trials in Primary Prevention of Sudden Cardiac Death 464
Current Implantable Cardioverter-Defibrillator Indication Guidelines 467
Remote Monitoring of Devices 469
Implantable Cardioverter-Defibrillator Programming 470
Cardiac Resynchronization Therapy 472
Wearable Cardioverter Defibrillators 475
Subcutaneous Implantable Cardioverter-Defibrillators 477
Real World Effectiveness 478
Conclusion 479
References 479
17 Subcutaneous and Epicardial Defibrillators 482
Subcutaneous Implantable Cardioverter-Defibrillator System: Technology and Development 482
Implantation 482
Effectiveness and Safety 482
Arrhythmia Detection, Sensitivity, and Discrimination 484
Indications 486
Limitations 486
4 Implantation Techniques 629
26 Permanent Pacemaker and Implantable Cardioverter-Defibrillator Implantation in Adults 631
Personnel 631
Physician/Surgeon 631
Support Personnel 631
Implantation Facility and Equipment 632
Preoperative Planning and Assessment 634
Inpatient Versus Outpatient Procedure 634
Additional Preoperative Patient Assessment 634
Preoperative Orders 635
General Information 636
Site Preparation and Draping 636
Anesthesia, Sedation, and Pain Relief 636
Antibiotic Prophylaxis and Wound Irrigation 637
Anatomic Approaches for Implantation 638
Transvenous Pacemaker Placement 641
Cephalic Venous Access 641
Subclavian Venous Access 642
Axillary Venous Access 643
Methods of Multilead Introduction 652
Multiple Separate Venipunctures and Use of Multiple Sheath Sets 652
One Percutaneous Puncture and Use of Large Sheath With Passage of Multiple Electrodes 652
Retained-Guidewire Technique 652
Sheath Set Technique With Cutdown Approach 652
Placement of the Right Ventricular Lead 653
Placement of Atrial Leads 658
Implantable Cartioverter-Defibrillator-Specific Lead Issues 660
Subcutaneous Defibrillation Electrodes 660
Azygos Vein Defibrillation Coil 660
Coronary Sinus Coil 660
Upgrading Techniques 660
Cardiac Implantable Electronic Devices Connectivity 661
Securing Leads, Creating Pockets, and Closure 662
Epicardial Lead Placemanent Placement of Epicardial Electrodes 665
Epicardial Approach 665
Median Sternotomy Approach 665
Left Anterolateral Thoracotomy Approach 665
Subxiphoid Approach 666
Left Subcostal Approach 666
Thoracoscopic Approach 667
Cosmetic Approach to Device Implantation 667
Submuscular Pectoral Pocket 668
Special Considerations and Situations 672
Use of the Iliac Vein 672
Transiliac Implantable Cardioverter-Defibrillator Implantation 673
Use of the Jugular Vein 673
Alternatives to Radiography during Implantation 674
Repositioning of Electrodes 675
Alternatives to Transvenous Lead Placement 675
Misplacement of Lead in Left Ventricle 679
Selective Site Pacing 680
General Considerations 680
Anatomic Considerations 681
Right Atrium 681
Right Ventricle 682
Radiographic Anatomy 683
Atrial Septal Pacing 684
Right Ventricular Selective Site Pacing 686
Direct His Bundle Pacing 687
The Future of Selective Site Pacing 688
Immediate Postoperative Care 688
References 689
27 Pacemaker and Implantable Cardioverter-Defibrillator Management in Children and Congenital Heart Disease 692
Pediatric Indications for Pacing 692
Sinus Node Dysfunction 692
Atrioventricular Node Dysfunction 693
Other Pacing Indications 694
Cardiac Resynchronization 695
Lead Implantation Technique 695
Epicardial Pacing 697
Other Considerations 697
Indications for Implantable Cardioverter-Defibrillator Implantation in Children and Adults with Congenital Heart Disease 698
Congenital Heart Disease 699
Patients with Inherited Arrhythmia Syndromes 700
Technical Considerations in Implantable Cardioverter-Defibrillator Implantation for Pediatric Patients and Patients with Congenital Heart Disease 700
Ventricular Fibrillation and “Defibrillation Testing” in Pediatrics 701
Approach to the Pediatric Patient with High Defibrillation Thresholds 701
Programming 702
Implantable Cardioverter-Defibrillator Programming Suggestions 703
Lead Complications 704
Psychosocial Aspects 706
Summary 706
References 707
28 Implantation of the Subcutaneous Implantable Cardioverter-Defibrillator 709
Identifying Candidates for Subcutaneous Implantable Cardioverter-Defibrillator Therapy 709
Patient Selection 709
Patient Assessment 709
General Considerations for Subcutaneous Implantable Cardioverter-Defibrillator Implantation 709
Personnel and Equipment 709
Planning of the Procedure 710
Preparation 711
Anesthesia 711
Patient Positioning 711
Incision Marking 711
Surgical Site Preparation 712
Implantation of the Subcutaneous Implantable Cardioverter-Defibrillator 712
Creating the Pocket 712
Lead Tunneling 712
Three-Incision Implantation Technique 713
Xiphoid-to-Superior Parasternal Tunneling 713
Two-Incision Implantation Technique 714
Placing the Device in the Pocket 714
Postoperative Care 715
Alternative Implant Positions 715
Submuscular Implantation 715
Sub-Serratus Anterior Position of the Can 715
Lead and Can Positions in Patients with Anatomic Variations 715
Troubleshooting 715
Device Extraction 715
Infection 715
Pocket Erosion 716
Defibrillation Threshold Testing Failure 716
Considerations for the Future 717
Conclusions 717
References 717
29 Intraprocedural Assessment of Stimulation, Sensing, Detection, and Defibrillation 718
Principles Related to Stimulation 718
Physiology of Cardiac Pacing 718
Determining Optimal Lead Position 718
Imaging for Lead Placement 718
Lead Placement 720
Right Atrial Leads 720
Right Ventricular Leads 720
Left Ventricular Leads 720
Evaluation for Extracardiac Stimulation 722
Assessing for Current of Injury 722
Wavelet Size, Slew Rate, and Lead Impedance 722
Sensed Signals 722
Pacing Capture Thresholds 722
Lead Impedance 722
Slew Rates 723
Stimulation Threshold Testing and the Strength-Duration Curve 723
Wedensky Effect and Wedensky Facilitation 724
Bipolar and Unipolar Stimulation 725
Cathodal and Anodal Stimulation 725
Capture Latency and Exit Block 726
Principles Related to Sensing 727
Physiology of Intracardiac Sensing 727
Near-Field and Far-Field Signals 728
Unipolar, Integrated Bipolar, and True Bipolar Sensing 728
Approach to Undersensing 728
Approach to Oversensing 729
Lead Issues 729
Metabolic and Structural Factors 730
Electromagnetic Interference 730
Sensing in Cardiac Resynchronization Devices 730
Principles Related to Arrhythmia Detection and Defibrillation Threshold Testing 730
Overview of Detection and Arrhythmia Discriminators 730
Intraprocedural Defibrillation Testing 734
Assessment of Sensing 734
Assessment of Defibrillation Margin 734
Evolution of Implantable Cardioverter-Defibrillator Testing 735
When Defibrillation Testing Should Be Considered 735
Contraindications to Defibrillation Testing 735
To Test or Not to Test? 735
Performance of Defibrillation Testing 736
References 736
30 Coronary Sinus Lead Implantation 739
Introduction 739
Left Ventricular Lead Position and Response 739
Newer Tools for Delivery of Coronary Venous Leads 743
Coronary Sinus Access Catheter 745
Telescoping Assist Catheter 745
Vein Selector 746
Inner Guide 746
Previous Approach to the Shape and Use of Inner Guides 746
New Approach to the Shape and Use of Delivery Guides 749
Left Ventricular Lead Implantation Using the Author-Designed Delivery System 749
Step-by-Step Summary 749
Left Ventricular Lead Implantation with the Worley Delivery System and Interventional Techniques 752
Details and Rationale 752
Prepare the Patient for the Use of Iodinated Contrast Material 752
Equipping and Setting up the Room 752
Collect Available Left Ventricular Lead Implantation Equipment and Review Its Use 752
Organize the Equipment to Be Readily Available in the Room 752
Assemble the “Always Used” Equipment on the Table before Starting 752
Pay Careful Attention to the Orientation of the Instrument Table during Various Stages of the Procedure 752
Approach to Contrast 753
Venous Access for Left Ventricular Lead Implantation 753
Preventing Restricted Catheter/Lead Movement 755
Separate Access for Each Lead 755
Axillary versus Subclavian Venous Access 755
Response to Subclavian Obstruction in Patient with Preexisting Leads 755
The Platform for Left Ventricular Lead Placement 756
Lumen Size 756
Catheter Shape 757
Cutting versus Peeling to Remove the Coronary Sinus Access Sheath 758
Coronary Sinus Access for Left Ventricular Lead Implantation 759
Contrast or Not for Coronary Sinus Cannulation? 760
Limitations of the Noncontrast Method 760
Limitation of the Contrast Method 761
Turning Failure Into Success With the Use of Contrast 761
Catheter Shape for Coronary Sinus Cannulation 761
Catheter Shape and the Anatomy Surrounding the Coronary Sinus Ostium (Case Study 30-1) 761
How to Locate the Ostium of the Coronary Sinus With Contrast Injection System 763
Coronary Sinus Cannulation: A Two-Step Process with Contrast Injection 764
Step 1: Locating the Ostium of the Coronary Sinus 764
Anatomy Surrounding the Coronary Sinus Ostium as Defined by Contrast Injection 765
Coronary Sinus Venous Anatomy 767
Half-Strength versus Full-Strength Contrast Agent 768
Occlusive Coronary Sinus Venography (CASE STUDY 30-2) 770
Measures to Overcome Failure to Visualize the Coronary Venous Anatomy 772
Selective Injection of the Coronary Veins 772
Blind Draw Back Technique 772
Focused Location and Injection of the Anterior or Middle Cardiac Veins 772
Selective Injection for the Persistent Left Superior Vena Cava 777
Coronary Artery Injection with Venous-Phase Images 777
Basic Patterns of the Coronary Venous Anatomy 777
Size Distribution 777
Cannulation of the Difficult Coronary Sinus 777
Finding the Difficult Coronary Sinus Ostium 777
Anatomic Variants That Make It Difficult to Locate 778
Step 2: Advancing a Sheath or Guide into the Coronary Sinus 778
If the Sheath/Guide Is Difficult to Advance 778
Anchor Balloon Technique 780
5 Follow-Up and Programming 959
36 Timing Cycles of Implantable Devices 961
Pacing System Code 961
Pacing Modes 961
Single-Chamber Pacing Modes 961
Single-Chamber Asynchronous Pacing (AOO, VOO) 961
Single-Chamber Inhibited Pacing (AAI, VVI) 961
Single-Chamber Triggered Pacing (AAT, VVT) 961
Dual-Chamber Pacing Modes 962
Dual-Chamber Asynchronous Pacing (DOO) 962
Dual-Chamber Tracking Modes (DDD, VDD) 963
Dual-Chamber Modes Without Tracking (DDI, VDI, DVI) 963
Dual-Chamber Triggered Modes 963
Timing Cycles of Single- and Dual-Chamber Pacing 963
Single-Chamber Pacing 964
Lower Rate Interval 964
Refractory Period 964
Timing Cycles in Different Single-Chamber Pacing Modes 965
Single-Chamber Asynchronous Pacing (AOO, VOO) 965
Single-Chamber Inhibited Pacing (AAI, VVI) 965
Single-Chamber Rate Hysteresis 965
Dual-Chamber Pacing 965
Overview of Dual-Chamber Timing Cycles 965
Lower Rate Interval 965
Atrioventricular Interval and Ventriculoatrial Interval 967
Refractory Periods 967
Upper Rate Interval 967
Blanking and Refractory Periods 968
Confusing Terminology Regarding Blanking and Refractory Periods 969
Atrioventricular Interval 970
Atrioventricular Crosstalk and Ventricular Safety Pacing 970
Differential Atrioventricular Interval 971
Dynamic or Rate-Adaptive Atrioventricular Interval 972
Atrioventricular Interval Hysteresis 972
Timing Cycles in Different Dual-Chamber Pacing Modes 973
Lower Rate (Base Rate) Timing 973
Ventricular-Based Timing 973
Atrial-Based Timing 973
Comparison of Atrial-Based and Ventricular-Based Timing 973
Hybrid Timing 973
Dual-Chamber Rate Hysteresis 975
Upper Rate Behavior 975
Sensor-Driven or Rate-Adaptive Pacing 978
Hemodynamics of Exercise and Basis for Rate-Adaptive Pacing 978
Timing Cycles of Sensor-Driven Pacing 978
Sensor Parameters 978
Rate-Adaptive Algorithms 979
Device Algorithms and Specific Features 979
Algorithms for Detection of, and Response to, Atrial Tachyarrhythmias (Mode Switching) 979
Timing Cycles for Mode Switching 979
Atrial Sensitivity 979
Comparison of Mode-Switching Algorithms 980
Ventricular Rate Control 981
Detection of Rapid Regular Atrial Tachyarrhythmias (Atrial Flutter) 983
Mode Switch Episodes Versus Atrial Tachycardia/Atrial Fibrillation Episodes 983
Algorithms for Prevention of Atrial Tachyarrhythmias 985
Algorithms for Prevention of Atrial Fibrillation by Pacing 985
Prevention of Pacing in the Atrial Vulnerable Period 985
Algorithms to Minimize Ventricular Pacing 989
Dynamic Atrioventricular Interval Prolongation (Atrioventricular Hysteresis) 989
Atrioventricular Mode Switch (Atrial Pacing to Dual-Chamber Pacing) 989
Algorithms for Rate Adjustment 992
Algorithms to Promote Transient Rapid Pacing (for Neurally-Mediated Syncope) 992
Algorithms to Promote Intrinsic Heart Rate 992
Noncircadian algorithms. 992
Circadian algorithms. 997
Algorithms to Prevent Sudden Variations in Rate 999
Prevention of Beat-Beat Variations in Rate 999
Tracking modes. 999
Nontracking modes (algorithms for regularization of ventricular rate in AF). 999
Rate Adjustment During Mode Switch 1000
Rate Regularization at the Upper Rate Limit 1000
Pacemaker-Mediated Atrioventricular Dyssynchronous Rhythms 1000
Classic Pacemaker-Mediated Tachycardia 1000
Algorithms for Prevention, Detection, and Termination of Pacemaker-Mediated Tachycardia 1002
Other Pacemaker Reentrant Tachycardias 1002
Repetitive Nonreentrant Ventriculoatrial Synchrony 1002
Response of Dual-Chamber Devices to Premature Ventricular Complexes 1008
Timing Cycles of Biventricular Pacing 1008
Goals of Biventricular Pacing 1008
Pacing, Sensing, and Timing 1008
Pacing 1008
Sensing 1008
Timing 1010
Timing Cycles 1010
Atrioventricular Interval and Interventricular (V-V) Interval 1010
Interventricular delay. 1010
Sensing within the AVI and the interventricular interval. 1010
Blanking and Refractory Periods 1011
Cross-chamber (atrial/ventricular). 1011
Same chamber. 1011
Interventricular refractory period. 1011
Double counting and triple counting in CRT devices. 1012
Lower Rate Interval and Lower Rate Timing 1012
Upper Rate Interval and Upper Rate Behavior 1013
TARP and iTARP 1013
Features to Promote Biventricular Pacing 1014
Suppression of Intrinsic Conduction/Response to Intrinsic Conduction 1014
Dynamic adaptation of A-V and V-V intervals. 1014
Triggered ventricular pacing. 1014
Biventricular pacing during atrial tachyarrhythmias. 1017
Prevention of Loss of Atrial Tracking (and Restoration of Tracking) 1020
Features to Prevent Pacing in the Ventricular Vulnerable Period 1020
Left Ventricular Protection Period 1020
Pacemaker-Mediated Atrioventricular Dyssynchronous Rhythms in Cardiac Resynchronization Therapy Devices 1020
Timing Cycles of Implantable Cardioverter-Defibrillators 1020
Blanking and Refractory Periods in Implantable Cardioverter-Defibrillators 1021
Ventricular Channel 1021
Atrial Channel 1022
Interaction between Pacing and Ventricular Tachyarrhythmia Detection 1022
Upper Limit of Pacing Versus Lower Limit of Ventricular Tachycardia Detection 1022
Conflict Between Pacing Parameters and Ventricular Tachyarrhythmia Detection 1023
Features to Promote Ventricular Tachyarrhythmia Detection 1023
Arrhythmia unhiding. 1025
Shortening of the atrioventricular delay. 1025
Bradycardia Functions Following Ventricular Tachycardia Detection and during/after Therapy for Ventricular Tachycardia/Ventricular Tachycardia Fibrillation 1025
Response to External Influences 1025
Noise Response 1025
Electrical Reset (Power-on Reset) 1027
Magnet Response 1027
References 1030
37 Pacemaker Programming and Troubleshooting 1031
Pacemaker Programming 1031
Pacing Mode 1031
DDD(R) 1031
DDI(R) 1031
ADI(R) 1031
VDD 1031
VDI(R) 1031
AAI(R) 1031
VVI(R) 1034
VVT 1034
VOO or DOO 1034
ODO or OVO or OAO 1034
OOO 1034
Baseline and Upper Rates 1034
Rate Response 1034
Pacing Output 1034
Sensitivity 1036
Atrioventricular Delay 1036
Pacemaker Troubleshooting 1037
Electrocardiograms in Patients with Pacemakers 1037
Pacing Pulse Artifacts 1037
Paced P-Wave Morphology 1038
Paced QRS Morphology 1038
Event Markers and Intracardiac Electrograms 1038
Failure to Pace (Nonpacing) 1040
Failure to Capture (Noncapture) 1042
Oversensing 1044
Far-Field R-Wave Oversensing 1044
Far-Field P-Wave Oversensing 1045
Near-Field Oversensing 1046
T-Wave Oversensing 1046
Myopotential Oversensing 1046
Oversensing of Nonphysiologic Signals 1046
Consequences and Management of Oversensing 1048
Failure to Sense (Undersensing) 1051
Specific Pacemaker Issues 1053
Crosstalk 1053
Pacemaker-Mediated Tachycardia 1054
Endless-loop tachycardia. 1055
Prerequisites. 1055
Detection and termination. 1055
Prevention. 1056
Atrial arrhythmias. 1057
Myopotential tracking. 1058
Sensor-driven tachycardia. 1059
Runaway pacemaker. 1059
Cross-Stimulation 1059
Repetitive Nonreentrant Ventriculoatrial Synchronous Rhythm 1059
Systematic Pacemaker Electrocardiogram/Electrogram Interpretation 1060
Conclusion 1062
References 1062
38 Implantable Cardioverter-Defibrillator Programming and Troubleshooting 1064
General Principles 1064
Initial Evaluation and Tools 1064
Clinical History 1064
Physical Examination 1064
Electrocardiographic Recordings 1065
Device Telemetry 1065
Radiographic Evidence 1067
Presentations 1072
Multiple Shocks 1072
Failure to Convert Ventricular Tachycardia or Ventricular Fibrillation 1083
Failure to Detect Ventricular Tachycardia or Ventricular Fibrillation 1083
Problems with Pacing 1086
Other Issues 1086
Summary 1087
References 1087
39 Cardiac Resynchronization Therapy Programming and Troubleshooting 1090
Introduction 1090
Cardiac Resynchronization Therapy Programming 1090
General Principles on Cardiac Resynchronization Therapy Programming 1090
Minimize Right Atrial Pacing 1090
Program Appropriate AV and VV Delays 1090
Program Adequate Pacing Output 1090
Program Higher Tracking Rates 1090
Appropriate Programming of Postventricular Atrial Refractory Period and Associated Algorithms 1090
Avoid Interruption of Cardiac Resynchronization Therapy Due to Arrhythmias 1090
Consider Algorithms to Promote Cardiac Resynchronization Therapy 1090
Recognize Anodal Capture on Electrocardiogram as a Reason for Nonresponse 1090
Strategies to Deal With Phrenic Nerve Capture 1091
Understand Optimization Algorithms, Outcomes, and Applicability to Individual Patients 1091
Device Manufacturer–Specific Cardiac Resynchronization Therapy Features 1091
Medtronic-Specific Cardiac Resynchronization Therapy Features 1091
Adaptive CRT. 1091
Multipolar LV pacing leads with additional LV pacing vectors. 1092
Ventricular-sense response. 1093
Conducted AF response. 1094
Atrial tracking recovery. 1094
Ventricular sense episodes. 1096
St. Jude Medical–Specific Cardiac Resynchronization Therapy Features 1096
Quick opt. 1096
Multipolar LV pacing leads with additional LV pacing vectors. 1096
RV-LV conduction time measurement. 1096
Trigger pacing. 1096
Negative AV/PV hysteresis. 1096
Boston Scientific Cardiac Resynchronization Therapy–Related Specific Features 1096
Smart delay. 1096
RV-LV delay. 1096
Multipolar LV pacing with additional LV pacing vectors. 1097
Ventricular rate regulation. 1097
BiV triggered pacing. 1097
LV sensing and protection periods. 1097
Tracking preference. 1097
Sorin-Related Specific Features 1097
Multiple LV pacing vectors. 1097
VV delay. 1097
SonR (endocardial acceleration sensor) hemodynamic optimization. 1101
Biotronik Devices: Cardiac Resynchronization Therapy–Related Features 1101
Multiple LV pacing vectors. 1101
LV pacing protection. 1101
Triggered LV pacing. 1101
VV delay. 1101
Negative AV hysteresis. 1101
Cardiac Resynchronization Therapy Troubleshooting 1101
Pacing Malfunction 1103
Noncapture 1103
Elevated Pacing Threshold 1106
Autocapture Failure 1107
Diaphragmatic stimulation. 1108
Anodal stimulation. 1110
Sensing Abnormality 1111
Double-Counting 1111
Oversensing 1112
Undersensing 1112
Generator 1112
Electromagnetic Interference 1113
Radiation Effect 1113
Proarrhythmia 1114
Cardiac Resynchronization Therapy Device and Other Cardiac Device Interaction 1114
Recognition and Management of Poor Response to Cardiac Resynchronization Therapy 1116
Pre-Cardiac Resynchronization Therapy Implant: Patient Selection 1116
Cardiomyopathy and Scar Burden 1116
Cardiac Resynchronization Therapy Implant: Optimal Left Ventricular Lead Position 1118
Postcardiac Resynchronization Therapy Management 1122
Inadequate Biventricular Pacing 1122
Cardiac Resynchronization Therapy Programming 1122
Atrial Fibrillation 1122
Premature Contractions 1123
AV and VV Programming 1127
Echo-guided optimization. 1127
Impedance cardiography. 1129
Finger photoplethysmography (FPPG). 1129
Acoustic cardiography. 1129
Electrocardiography. 1129
References 1131
40 Follow-Up of Cardiac Implantable Electronic Devices—Remote Monitoring and in Person 1133
Monitoring Goals 1133
In-Person Monitoring 1133
Remote Technologies 1133
Transtelephonic Monitoring Without Interrogation 1133
Modern Systems 1134
Remote Management 1135
Clinical Applications 1135
Outpatient Clinic Workload Reduction and Optimization 1135
Device Managment 1136
Lead and Device Performance 1136
Advisories 1142
Disease Management 1142
Arrhythmias 1142
Atrial Fibrillation 1142
Ventricular Arrhythmias 1145
Heart Failure 1145
Implementing Remote Monitoring 1145
Device Clinic 1149
The Organizational Model 1150
Role and Responsibilities of the Patient 1153
Patient Acceptance and Satisfaction 1153
Economics 1153
Data Management 1154
Regulatory Issues 1155
Medicolegal Issues 1155
Summary 1155
References 1156
41 Perioperative and Periprocedural Management, Electromagnetic Interference, and Cardiac Implantable Electronic Devices 1158
Considerations for Patients with Cardiac Implantable Electronic Devices Undergoing Surgical OR Invasive Procedures 1158
Clinical Status Affecting Arrhythmic Risk OR Device Function 1158
Electromagnetic Interference 1158
Oversensing 1158
Device Reset 1159
Damage to the Lead-Tissue Interface 1159
Battery Life 1159
Changes in Programming 1159
Physical Damage to the Cardiac Implantable Electronic Device Related to Surgical Procedures 1159
Preoperative Evaluation of the Patient with a Cardiac Implantable Electronic Device OR Arrhythmias 1159
Role of the Electrophysiology/ Cardiology Team 1159
Role of the Anesthesiology/Surgical Team 1161
Reprogramming Versus Magnet Use 1162
Reprogramming the Cardiac Implantable Electronic Device 1162
Magnet Response 1162
No Reprogramming OR Magnet Use 1164
Subcutaneous Implantable Cardioverter-Defibrillator 1164
Novel Pacemakers 1165
Implantable Loop Recorders 1166
Emergency Procedures 1166
Intraoperative Management of the Patient with a Cardiac Implantable Electronic Device 1166
Intraoperative Monitoring 1166
Central Venous Catheter Placement and Cardiac Implantable Electronic Device Leads 1166
Location of the Electrosurgical Return Patch 1167
Postoperative Management of the Patient with a Cardiac Implantable Electronic Device 1167
Mechanism of Specific EMI Sources and Risk to the Cardiac Implantable Electronic Device 1167
Electrosurgical Energy 1167
Direct Current Cardioversion 1168
Radiofrequency Ablation 1168
Diagnostic Radiation 1168
Therapeutic Radiation 1169
Electroconvulsive Therapy 1170
Transurethral Resection of the Prostate/Transurethral Needle Ablation 1170
Colonoscopy/Gastroscopy 1170
Ocular Procedures 1170
Magnetic Drapes 1170
Tissue Expanders with Magnets 1170
Transcutaneous Electrical Nerve Stimulation/Spinal Cord Stimulators 1170
Radiofrequency Identification Devices 1170
Electromyography and Nerve Conduction Velocity Studies 1170
Lithotripsy 1171
Argon Plasma Coagulation 1171
Procedures with No Risk 1171
Electromagnetic Interference in the Nonmedical Environment 1171
Cellular Telephones and Other Home Electronics 1171
Industrial Equipment and Occupational Exposures 1171
Security Systems 1172
Scuba Diving and Hyperbaric Oxygen 1172
Conclusion 1172
References 1173
42 Managing Advisories of Cardiac Implantable Electronic Devices 1175
Introduction 1175
Device Performance 1175
Types of Advisories 1175
Review of Device Advisories 1176
Generator-Associated Device Advisories 1176
Lead-Associated Advisories 1178
The Sprint Fidelis Lead Advisory 1181
The Riata Lead Advisory 1182
Approach to the Patient with an Advisory 1185
Lead Advisory Versus Generator Advisory 1187
Current Surveillance Mechanisms 1187
Conclusion 1189
References 1189
43 Establishing and Managing a Device Clinic and Database 1191
Clinics for the Follow-Up of Cardiovascular Implantable Electronic Devices 1191
Increased Cardiovascular Implantable Electronic Device Follow-Up Volume 1191
Goal of Cardiovascular Implantable Electronic Device Follow-Up 1191
Personnel Involved in Cardiovascular Implantable Electronic Device Follow-Up 1191
Paradigms for Cardiovascular Implantable Electronic Device Follow-Up Including Remote Monitoring 1192
Organization of a Pacemaker Follow-Up (in-Person) 1193
Organization of an Implantable Cardioverter-Defibrilltor Follow-Up (in-Person) 1193
Organization of the Follow-Up of a Cardiac Resynchronization Therapy Device (CRT-P or CRT-D) 1195
Organization of Remote Follow-Up for Cardiovascular Implantable Electronic Devices 1195
Cardiovascular Implantable Electronic Device Database Integration 1196
Implementation, Health Economics and Reimbursement 1197
References 1199
44 Social and Ethical Principles of Device Therapy 1201
The Ethics of Cardiac Implantable Electronic Device Reuse 1201
Disparities in Access to Cardiac Implantable Electronic Devices 1201
Donations to Improve Access to Cardiac Implantable Electronic Device Therapy 1201
Potential Sources of Reused Devices 1201
Support for Cardiac Implantable Electronic Device Reuse on Humanitarian Grounds 1202
Evidence in Favor of Safety and Efficacy of Cardiac Implantable Electronic Device Reuse 1202
Legal Obstacles, Regulatory Considerations, and Solutions 1203
Ethical Considerations of Cardiac Implantable Electronic Device Reuse 1203
Responsibilities of the Reprocessor 1205
Conclusions 1205
The Ethics of Cardiac Implantable Electronic Device Deactivation in Terminally Ill Patients 1206
Ethical and Legal Foundations of End-of-Life Care and Applications to Cardiac Implantable Electronic Devices 1206
Cardiac Implantable Electronic Device Function Near the Time of Death 1206
Views on Cardiac Implantable Electronic Device Deactivation 1207
Heart Rhythm Society Consensus Statement of 2010 1207
The Ethics of Deactivating Cardiac Implantable Electronic Device Therapies 1207
Physician Agency 1208
Discussing the Role of Cardiac Implantable Electronic Device Therapy with Patients 1208
Logistics of Cardiac Implantable Electronic Device Activation 1208
Device Deactivation Plan 1209
Reprogramming the Cardiac Implantable Electronic Device 1209
Inpatient Care Settings 1209
Patients at Home or Outside of Inpatient Medical Facilities 1209
Pediatric Patients 1209
Conclusions 1209
References 1210
Index 1211
A 1211
B 1213
C 1214
D 1217
E 1218
F 1219
G 1220
H 1220
I 1221
J 1222
K 1222
L 1222
M 1224
N 1224
O 1225
P 1225
Q 1227
R 1227
S 1228
T 1230
U 1231
V 1231
W 1232
X 1232
Z 1232
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