Discussion for "A Change of Pace: What Happened?"

This is the discussion for "A change of Pace: What Happened?"  My apologies for the delay!

Pacemakers are amazing pieces of technology. They have evolved continually, and have given patients an increasing quality of life where none existed before.

However, with this amazing technology comes a level of complexity that also has not been seen before. These are remarkable devices, cable of many, many different types of functions. Sensing, pacing, defibrillating, single chamber, dual chamber, atrial paced, ventricular paced, cardiac resynchronization, etc… you get the idea. These are just some of the diverse functions that these devices can perform.

For us, we don't often know what type of pacemaker we are dealing with. And often, our patients do not know either! This created a dilemma for us, when we are confronted with an ill patient, and a pacemaker functioning in a way that we do not often see. Is it performing properly? Or is it performing inappropriately? Is the patient's complaint related to the pacemaker function, or the pacemaker reacting to the illness of the patient? To adequately answer these questions, we have to be able to figure our whether the pacemaker is functioning as it should, and why it is behaving this way.

To this end, I have enlisted the help of Mark Perrin, author of the EP Fellow blog. Peer sourcing is an amazing resource!

We'll go through these strips one at a time.

First, let's revisit the first ECG:

There appears to be a sinus rhythm at a rate of about 75bpm. The PR interval is about 240ms, and the QRS duration is slightly prolonged at about 110ms. There are pacing spikes that appear at the onset of the QRS. There also appears to be a fairly constant interval of 140ms between the P wave and the pacing spike.

So, what is going on here? Are the ventricles being paced by the pacemaker?

The first thing to understand is that the site of the pacing lead is normally in the right ventricle. Most of us already know that. However, what we may not all know is that the pacing lead sees "local activation", not the QRS that we see on the surface ECG. 

Mark Perrin: "A pacing spike on the beginning of the QRS is not uncommon. It usually occurs because of a right bundle branch block of a right ventricular conduction delay. The pacing lead is in the RV, therefore if there is delay to the right ventricle, activation of the LV (through a conducted P through the AV node) may occur just before the RV lead paces. The RV lead paces because it has not seen LV activation."

Essentially, there is an atrial sensing window of 140ms in this case. If there is a QRS that occurs within that sensing window, the pacing spike will be inhibited. If there is no QRS impulse sensed, the pacing lead will pace. Because of the conduction delay, the beginning of the QRS (which we see) is not seen by the pacer due to the conduction delay, so it paces, even though the ventricle is already responding to the P wave. What should happen, if this occurs, is that the pacing spike should always be near the beginning of the QRS. If it is, as it is in this case, nothing needs to be done, as this is what you could call a "normal variant".

What about the pause near the end of the strip, followed by the complex that looks different from the rest? You may also notice that the P wave looks a little different as well:

 

Mark Perrin: "This probably occurs because of a different degree of fusion between the conducted LV activation and RV pacing. The change in the apparent AV interval occurs again because the atrial lead sees "local" activation, not the P wave on the surface ECG. Therefore if the atrial activation occurs closer to the AV node it may start conducting to the ventricle before the wavefront reaches the atrial sensing bipole and triggers ventricular pacing. The opposite also occurs, i.e. atrial activation is further from the node, and reaches the atrial sensing bipole long before getting to the AV node."

Let's take a look at the second strip again:

This strip is a variation on the theme of the first. This strip has a mixture of the complexes seen on the first ECG, some with varying degrees of  fusion, plus a fully paced beat near the end of the strip. Why the fully paced beat here?

Mark Perrin: "The fully paced beat occurs (my guess) because the PVC before it invades the AV node thus delaying conduction down the node on the following beat."

Now on to the third ECG:

Here we see a fully paced rhythm at a rate of about 85bpm. Why the change from the prior rhythm to a fully paced rhythm?

To fully understand this, we have to remember a bit of physiology. In older people, or others likely to have diseased conduction systems, the "native" AV interval often increases when the heart rate increases. As the sinus rate increases, as in this case, the native AV interval also increases to the point where it is now longer than the pacemaker AV interval. Anytime the pacemaker AV interval is shorter than the native AV interval we won't see normal conduction anymore as the pacemaker takes over.

For this patient, these strips show normal pacemaker behavior. The main concept to remember is that the pacemaker does not see what wee see on the surface ECG. The pacemaker see local activation which may occur after the onset of the QRS in the ventricles, or after the onset of the P in the atria.

Many thanks again to Mark Perrin. I hope you have learned as much as I have in this case. I find pacemaker rhythms to be challenging but rewarding.  They can behave in so many different ways..Normally sometimes, and abnormally others. They really are incredible pieces of technology, and I one day aspire to really master the many ways in which they work. One day!

 

 

 

5 Comments

  • Mubeen Malik says:

    Good Discussion ! A nice move on internet for CME for docs. Keep it on !

  • VinceD says:

    Sorry for the slow response, but I thought I had this one figured out and have been lazy about actually following up. I understand what you're saying about the last ECG and how AV nodal conduction will tend to decrease with an increasing atrial rate, but that doesn't seem to be the full story on what's happening there.
    The P-wave to V-spike interval (term I made up) in the first tracing is clearly in the ballpark of 200-240ms, which seems like it's a bit long to me considering typical settings, but whatevs, that's what I see. Then, with the increased sinus rate in the third tracing, the pacemaker decides that it needs to fire with a much shorter P-wave to V-spike interval in the range of 120-140ms.
    This seems to me to be more than a simple case of usurption by the ventricular pacemaker. If that were indeed the case, the QRS's would look the same as they do now, evolving from fusion to pure ventricular-paced complexes across the tracings, but the time from the P-wave to the V-spike would remain the same, around 200ms.
    Instead, based purely off these tracings since my knowledge of implantable pacemakers is quite lacking, I would think there must be a setting built into the pacemaker to decrease the PRi as the sinus rate increases, because that is the only way I can account for what I'm seeing.
    Thanks for the great case, and I'm looking forward to your feedback.

  • David Baumrind says:

    As a follow up to VinceD's excellent points, I have some follow up from the esteemed Dr. Mark Perrin.

    The "P-wave to V-spike" interval will be shortened by the pacemaker to adjust for the increased heart rate.

    This is done to mimic normal physiology as much as possible. There apparently is no end to what these devices can do!

  • Naoto says:

    I a small surprised reivwes I found internet regarding unit. I received Christmas year used 10 times now running P90X program I doing. I , dead nuts readings,(within 1%) I give a A- . I never a problem getting a reading, problem read ?? engineering functionality gets a D . I’m engineer maybe I a small tougher impress, I VERY disappointed design. , I 20/10 vision (better average) normal light,lighting gym, basement I treadmill numbers nearly impossible read. numbers LCD close together, instance, a heart rate 152 easily mistaken 162 ,even 13yo son eagle eyes. one day wearing read thing? a Indiglo type backlight, , I found turn light take a pulse reading, light goes out before a reading. , take a pulse reading hit light catch reading before lose light. suppose extent light 2 secs hitting button light , never worked . better design pulse reading come full screen another touch a button, a period.Being engineer I know quite locked one aspect product working without looking over picture, being Usable! features seemed work fine, again, ‘t read . I very frustrated lack forethought.[...]

  • school says:

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    and it has helped me out loads. I’m hoping to contribute & assist other users like its helped me.
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EMS 12-Lead

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Comments
Arlene R
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It has been very insightful for me as i read this post. Thanks to the may people who commented. Like many nurses, I was also taught to differentiate svt from st by rate and now I stand corrected. I have a Telemetry test coming up soon, I wont have the patient in front of me…
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[…] Last week, I described the case of a middle-aged male with a vague history of heart failure who had been having progressive shortness of breath for 4-5 days. On the day he called 911, he had been walking a short distance when he syncoped. EMS obtained an ECG: […]
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I believe this may be coronary artery vasospasm.
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Ian Fudge
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this is really interesting because something similar happened to a patient as I sat them up in bed after delivering them to a community hospital in fact I even turned to his son and said "does dad suffer with epilepsy?" And then turned back and realised he wasn't breathing
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