Fundamento: A estimulação endocárdica convencional do ventrículo direito em ápice ou na região subtricuspídea ocasiona grande alargamento do QRS e importante dessincronização do miocárdio comprometendo a função ventricular. Com o surgimento da estimulação bifocal do VD e com a necessidade de estimulação cardíaca menos deletéria, a estimulação septal do VD tem sido cada vez mais utilizada. Eventualmente têm sido relatados limiares de estimulação mais altos e ondas R menores na estimulação septal. Objetivo: Comparar os parâmetros eletrofisiológicos das estimulações apical e septal, no mesmo paciente, para verificar se existem diferenças que possam interferir na escolha do ponto de estimulação. Este não é um estudo de ressincronização, porém tem o objetivo de contribuir na busca de uma estimulação ventricular monofocal menos deletéria. Casuística e métodos: Estudo prospectivo controlado. Foram incluídos 25 pacientes, com 67,2 ± 9 anos, 10 (40%) mulheres, 15 (60%) homens, com indicações clássicas de marca-passo por bradiarritmias. As etiologias foram Degenerativa em 9 (36%), Insuficiência coronária em 8 (32%), Doença de Chagas em 7 (28%), e Valvopatia em 1 (4%) pacientes. Foram utilizados eletrodos de fixação ativa tanto no ápice e região subtricuspídea, como no septo IVD. Foram medidos e comparados os limiares de comando, impedância e onda R uni e bipolares no momento do implante (medida direta) e após seis meses de evolução (medida por telemetria). Resultados: No implante, as médias dos limiares de comando septais x apicais foram respectivamente 0,73 x 0,74V (unipolar) e 0,73 x 0,78V (bipolar). As médias das ondas R septais x apicais foram 10 x 9,9mV (unipolar) e 12,3 x 12,4mV (bipolar). As médias das impedâncias septais x apicais foram 579 x 621? (unipolar) e 611 x 629? (bipolar). Todas as diferenças entre parâmetros septais e apicais com teste t-pareado bicaudal foram não significativas (p > 0,1). Após seis meses do implante, as médias dos limiares de comando septais x apicais foram respectivamente 0,5 x 0,72V (unipolar) e 0,71 x 0,87V (bipolar). As médias das ondas R septais x apicais foram 11,4 x 9,5mV (unipolar) e 12 x 11,2mV (bipolar). As médias das impedâncias septais x apicais foram 423 x 426? (unipolar) e 578 x 550? (bipolar). As diferenças entre parâmetros septais e apicais após 6 meses com teste t-pareado bicaudal foram não significativas (p > 0,05), exceto quanto às médias dos limiares de estimulação unipolares septal x apical (p=0,02) com menores limiares septais. 27, Conclusão: Este estudo mostrou que não existem diferenças expressivas entre parâmetros eletrofisiológicos de estimulação septal e apical, quando comparadas no mesmo paciente. Estes dados sugerem que em relação aos parâmetros de estimulação não há restrições para a escolha da estimulação septal em ventrículo direito. Este estudo não tem o objetivo de testar a ressincronização ventricular, porém contribui na escolha de uma estimulação monofocal ventricular direita mais fisiológica e menos deletéria. / Background: The conventional endocardial pacing in right ventricular apex or subtricuspid area causes significant QRS enlargement and important left ventricular desynchronization with ventricular function damage. By the introduction of RV bifocal pacing and the need of a less deleterious ventricular stimulation right ventricular septal pacing has been increasingly used. However, despite rare, some authors have reported high pacing thresholds and low R wave in septal pacing. Objective: To compare the electrophysiological parameters of the apical and septal stimulation in the same patient, seeking for any difference that could affect the choice of the pacing point. This is not a resynchronization study however it has the aim to search for for a better monofocal ventricular pacing. Materials and methods: Prospective controlled study of 25 symptomatic patients (67.2 ± 9 years old, 10 [40%] female, 15 [60%] male) having permanent atrial fibrillation with high degree AV block and classical pacemaker indication. The etiologies were 9 (36%) aging, 8 (32%) coronary disease, 7 (28%) Chagas disease and 1 (4%) valvar cardiopathy. There were used active fixation leads both in septal and in apical locations. The generators were Biotronik Philos II DR and Entovis DR. There were measured and compared pacing thresholds, impedance and R wave uni and bipolar during implantation (direct measurement) and after six months of follow-up (telemetry measurement). Results: During implantation, the septal vs apical mean pacing threshold were respectively 0.73 vs 0.74V (unipolar) and 0.73 vs 0.78V (bipolar). Mean R wave septal vs apical were 10 vs 9.9 mV (unipolar) and 12.3 vs 12.4mV (bipolar). The mean impedance septal vs apical were 579 vs 621? (unipolar) and 611vs 629? (bipolar). All septal vs apical comparisons were non-significant (p > 0.1, two-tailed paired t-test). After six months the mean pacing threshold septal vs apical were respectively 0.5 vs 0.72V (unipolar) and 0.71 vs 0.87V (bipolar). The mean R wave septal vs apical were 11.4 vs 9.5mV (unipolar) and 11.2 vs 12mV (bipolar). The mean impedance septal vs apical were 423 vs 426? (unipolar) and 578 vs 550? (bipolar). Only the unipolar septal vs apical mean threshold had significant difference (p = 0.02) with lower septal value. Conclusion: This study showed no significant difference between electrophysiological septal and apical pacing parameters when the 29 comparison is done in the same patient. By this way there are no restrictions for the right ventricular septal pacing. Despite being a non-resynchronization study it may contribute for chosen a less deleterious right ventricular monofocal pacing.

No description available.

Fundamento: A estimulação endocárdica convencional do ventrículo direito em ápice ou na região subtricuspídea ocasiona grande alargamento do QRS e importante dessincronização do miocárdio comprometendo a função ventricular. Com o surgimento da estimulação bifocal do VD e com a necessidade de estimulação cardíaca menos deletéria, a estimulação septal do VD tem sido cada vez mais utilizada. Eventualmente têm sido relatados limiares de estimulação mais altos e ondas R menores na estimulação septal. Objetivo: Comparar os parâmetros eletrofisiológicos das estimulações apical e septal, no mesmo paciente, para verificar se existem diferenças que possam interferir na escolha do ponto de estimulação. Este não é um estudo de ressincronização, porém tem o objetivo de contribuir na busca de uma estimulação ventricular monofocal menos deletéria. Casuística e métodos: Estudo prospectivo controlado. Foram incluídos 25 pacientes, com 67,2 ± 9 anos, 10 (40%) mulheres, 15 (60%) homens, com indicações clássicas de marca-passo por bradiarritmias. As etiologias foram Degenerativa em 9 (36%), Insuficiência coronária em 8 (32%), Doença de Chagas em 7 (28%), e Valvopatia em 1 (4%) pacientes. Foram utilizados eletrodos de fixação ativa tanto no ápice e região subtricuspídea, como no septo IVD. Foram medidos e comparados os limiares de comando, impedância e onda R uni e bipolares no momento do implante (medida direta) e após seis meses de evolução (medida por telemetria). Resultados: No implante, as médias dos limiares de comando septais x apicais foram respectivamente 0,73 x 0,74V (unipolar) e 0,73 x 0,78V (bipolar). As médias das ondas R septais x apicais foram 10 x 9,9mV (unipolar) e 12,3 x 12,4mV (bipolar). As médias das impedâncias septais x apicais foram 579 x 621? (unipolar) e 611 x 629? (bipolar). Todas as diferenças entre parâmetros septais e apicais com teste t-pareado bicaudal foram não significativas (p > 0,1). Após seis meses do implante, as médias dos limiares de comando septais x apicais foram respectivamente 0,5 x 0,72V (unipolar) e 0,71 x 0,87V (bipolar). As médias das ondas R septais x apicais foram 11,4 x 9,5mV (unipolar) e 12 x 11,2mV (bipolar). As médias das impedâncias septais x apicais foram 423 x 426? (unipolar) e 578 x 550? (bipolar). As diferenças entre parâmetros septais e apicais após 6 meses com teste t-pareado bicaudal foram não significativas (p > 0,05), exceto quanto às médias dos limiares de estimulação unipolares septal x apical (p=0,02) com menores limiares septais. 27, Conclusão: Este estudo mostrou que não existem diferenças expressivas entre parâmetros eletrofisiológicos de estimulação septal e apical, quando comparadas no mesmo paciente. Estes dados sugerem que em relação aos parâmetros de estimulação não há restrições para a escolha da estimulação septal em ventrículo direito. Este estudo não tem o objetivo de testar a ressincronização ventricular, porém contribui na escolha de uma estimulação monofocal ventricular direita mais fisiológica e menos deletéria. / Background: The conventional endocardial pacing in right ventricular apex or subtricuspid area causes significant QRS enlargement and important left ventricular desynchronization with ventricular function damage. By the introduction of RV bifocal pacing and the need of a less deleterious ventricular stimulation right ventricular septal pacing has been increasingly used. However, despite rare, some authors have reported high pacing thresholds and low R wave in septal pacing. Objective: To compare the electrophysiological parameters of the apical and septal stimulation in the same patient, seeking for any difference that could affect the choice of the pacing point. This is not a resynchronization study however it has the aim to search for for a better monofocal ventricular pacing. Materials and methods: Prospective controlled study of 25 symptomatic patients (67.2 ± 9 years old, 10 [40%] female, 15 [60%] male) having permanent atrial fibrillation with high degree AV block and classical pacemaker indication. The etiologies were 9 (36%) aging, 8 (32%) coronary disease, 7 (28%) Chagas disease and 1 (4%) valvar cardiopathy. There were used active fixation leads both in septal and in apical locations. The generators were Biotronik Philos II DR and Entovis DR. There were measured and compared pacing thresholds, impedance and R wave uni and bipolar during implantation (direct measurement) and after six months of follow-up (telemetry measurement). Results: During implantation, the septal vs apical mean pacing threshold were respectively 0.73 vs 0.74V (unipolar) and 0.73 vs 0.78V (bipolar). Mean R wave septal vs apical were 10 vs 9.9 mV (unipolar) and 12.3 vs 12.4mV (bipolar). The mean impedance septal vs apical were 579 vs 621? (unipolar) and 611vs 629? (bipolar). All septal vs apical comparisons were non-significant (p > 0.1, two-tailed paired t-test). After six months the mean pacing threshold septal vs apical were respectively 0.5 vs 0.72V (unipolar) and 0.71 vs 0.87V (bipolar). The mean R wave septal vs apical were 11.4 vs 9.5mV (unipolar) and 11.2 vs 12mV (bipolar). The mean impedance septal vs apical were 423 vs 426? (unipolar) and 578 vs 550? (bipolar). Only the unipolar septal vs apical mean threshold had significant difference (p = 0.02) with lower septal value. Conclusion: This study showed no significant difference between electrophysiological septal and apical pacing parameters when the 29 comparison is done in the same patient. By this way there are no restrictions for the right ventricular septal pacing. Despite being a non-resynchronization study it may contribute for chosen a less deleterious right ventricular monofocal pacing.

An experimental study, using a pretest-posttest control group design, was conducted in a 570 bed acute care teaching hospital. Its purpose was to evaluate the effect of planned patient teaching and psychological support on the ability of the elderly patient to adapt to the surgical insertion of a permanent cardiac pacemaker. Nine subjects, who met the study criteria, were randomly assigned to either the experimental or control group. Each subject was asked if he would like to include a significant other in the project. The members of the experimental group (5 patients, 3 significant others) were seen individually by the nurse investigator on or close to the third, fourth and fifth postoperative day at which time their questions were answered, they were given the opportunity to express their concerns and, they were shown a 15 minute slide-tape programme about pacemakers. The members of the control group (4 patients, 4 significant others) were provided with the usual nursing care given by the ward nursing staff. All patients received a booklet from the company supplying their specific type of pacemaker. The hypotheses tested were: 1. Patient teaching and psychological support will increase the knowledge base of the patient and his significant other. 2. Patient teaching and psychological support will decrease the state and trait anxiety levels of the patient and his significant other. 3. Patient teaching and psychological support will enable the patient and his significant other to demonstrate pulse taking. 4. Patient teaching and psychological support will maintain or increase the activity level of the patient from his preoperative state. At approximately two and four weeks after discharge from the hospital, the nurse investigator visited all the patients in the study and their significant others. Knowledge base, anxiety (state and trait) level, activity level and pulse taking ability were measured on all patients; whereas, only knowledge base, pulse taking ability and anxiety (state and trait) level were measured on all significant others. No significant differences were found between the two groups on any of these variables. Some methodological problems and clinical implications of the findings are discussed. / Applied Science, Faculty of / Nursing, School of / Graduate

Fracture of a pacemaker lead is one of the most common causes of pacemaker malfunction. Lead fractures are seen in approximately 4 % of patients with pacemakers. We present a rare case of complete severance of the tip of a dual chamber pacemaker atrial lead. A 62 years old male presented for a routine device check of his pacemaker, which was originally implanted in 2002 for sick sinus syndrome and had a generator change in 2010. Device check showed a dual chamber pacemaker with right atrial and right ventricular leads and a remaining battery life of 8.6 years. Patient was not pacemaker dependent. Ventricular lead showed normal sensing, impedance and pacing threshold. Atrial lead showed unusually high impedance of 2175 ohms and no capture on testing at voltages as high as 7.5 mV. Further evaluation was done due to abnormal atrial lead test. An EKG was obtained showing normal sinus rhythm and atrial pacing spikes with no capture. Chest X-ray revealed a complete severance and dislocation of the atrial lead tip and an intact ventricular lead. A detailed history was obtained, and patient denied any trauma to the chest or upper extremities, chest pain, shortness of breath, palpitations, syncope or presyncope. Upon further history, patient reported a recent visit to theme park and enjoying high thrill rides. On examination, there were no signs of trauma, erythema, swelling, warmth, drainage or erosion at implant site. The pacemaker setting was changed from DDDR to VVIR, with plans to cap the proximal port of the fractured lead and placing a new atrial lead. Pacemaker lead fractures are reported with an incidence rate of 0.1 to 4.2 % per patient year [1]. The most common site of lead fracture is at the site of entry (40%) followed by between the entry site and generator (28%), close to the generator site (23%) and only (7%) are intravascular fractures [1]. Trauma and subclavian crush syndrome are the most commonly reported causes of pacemaker lead fractures. Pacemaker lead fracture due to physical exertion is an uncommon cause of lead malfunction [2]. Few cases have been reported of traumatic lead fracture due to the blunt chest trauma [3]. Patients with a lead fracture may present with symptoms of dizziness, syncope, chest discomfort, palpitations or, less commonly extra cardiac symptoms like hiccups or may completely be asymptomatic as seen in our patient. Diagnosis can be made by electrogram during device check, ECG and careful review of chest imaging such as chest x ray or fluoroscopy. Treatment is placement of a new lead with or without extraction of the fractured lead. This rare case of pacemaker lead fracture after a theme park ride indicates there may be a risk to pacemaker leads with high velocity amusement park rides which are becoming popular. This may have clinical implications such as a need for caution during amusement park visits and routine pacemaker interrogations after such visits especially in pacemaker dependent patients. References: 1: Alt E, Völker R, Blömer H: Lead fracture in pacemaker patients. Thorac Cardiovasc Surg.1987, 35:101-4.10.1055/s-2007-1020206 2: ohm J: Displacement and fracture of pacemaker electrode during physical exertion. Report on three cases. Acta Med Scand.1972, 192:33-5.10.1111/j.0954-6820.1972.tb04774 3: Bőhm A1, Duray G, Kiss RG: Traumatic Pacemaker lead fracture. Emerg Med J.2013, 30:686.10.1136/emermed-2012-202090.

Pacemaker implantation can be associated with several complications, including myocardial perforation with or without pericardial effusion, venous thrombosis, vegetations of the tricuspid valve (TV) or pacing lead, and tricuspid regurgitation (TR). The TR is thought to be derived from deformity or perforation of the TV by the pacing lead or secondary to atrioventricular discordance with asynchronous ventricular pacing. Severe TR can be deleterious to the patient because it raises the central venous pressure by increasing the right sided preload. Chronically, the increase in right sided blood volume can result in an increase in the right atrial pressure leading to a decrease in venous return and low cardiac output. Severe TR from leaflet adhesion to the pacemaker lead has not been reported before. With the aging of the population and the expanding use of pacemakers and implantable cardioverter defibrillators (ICD) in clinical practice, this complication may be seen more frequently. We present a patient diagnosed with severe TR, years after his pacemaker implantation. His TR was thought to be caused by adhesion of the tricuspid valve to his pacemaker lead.

Bakgrund Idag lever cirka 44 000 personer med pacemaker i Sverige. Pacemakerbehandling kan vara indicerat vid atrioventrikulärt block (AV-block), grenblock, sick sinus syndrome, förmaksflimmer med ventrikulär bradykardi och rytmrubbningar efter hjärtinfarkt eller hjärtkirurgi. Dessa tillstånd kan leda till en för långsam puls eller för långa pauser mellan hjärtslagen. Vid en för långsam puls är vanliga symtom trötthet och nedsatt fysisk kapacitet. Vid långa pauser mellan hjärtslagen kan yrsel och återkommande svimningsanfall uppkomma. Pacemakerns funktion är att känna av hjärtrytmen och skicka elektriska impulser som initierar hjärtslag med syftet att upprätthålla en adekvat slagfrekvens. Det är vid omvårdnaden av personer med pacemaker viktigt att sjukvårdspersonalen inte endast fokuserar på teknologin eftersom personens emotionella behov då inte möts. Vilket behov av stöd och information som finns hos personer med pacemaker kan belysas genom en ökad kunskap om hur livsstilen och livskvaliteten påverkas efter pacemakerinsättningen. Syfte Syfet var att beskriva hur personer med pacemaker upplever sin livskvalitet i det dagliga livet samt beskriva vilka livsstilsförändringar som kan uppkomma efter pacemakerinsättning. Metod En forskningsöversikt har använts för genomförandet av denna studie. Forskning inom området samlades in via databaserna PubMed och Cinahl under Mars 2011. Totalt inkluderades 15 vetenskapliga artiklar som sammanställdes i en integrerad analys. Resultat Personer genomgick livsstilsförändringar efter pacemakerinsättning på grund av rädsla för att skada eller störa pacemakern. Att ha en pacemaker upplevdes inte som något onormalt av personerna och pacemakern sågs som en förutsättning för att kunna leva ett lika aktivt liv som innan sjukdomen. Förbättringar av energi, vitalitet, symtom, social funktion, fysisk funktionsförmåga, fysisk livskvalitet, mental hälsa och emotionell livskvalitet skedde efter pacemakerinsättningen. Även rollbegränsningar relaterade till fysisk funktionsförmåga och emotionella rollbegränsningar minskade. Slutsats Livskvaliteten förbättrades signifikant efter pacemakerinsättning. Den största ökningen i livskvalitet skedde mellan den första och tredje månaden efter pacemakerinsättningen. Därefter minskade den fysiska livskvaliteten sakta medans den mentala livskvaliteten fortsatte att förbättras. Personer som fått en pacemaker genomgick både positiva och negativa förändringar av livsstilen på grund av förbättringen av hälsa samt rädslor och osäkerhet kring pacemakern.

Bakgrund: Idag lever många med kardiovaskulära sjukdomar framförallt hjärtarytmier och / eller hjärtstillestånd vilket är en av de vanligaste dödsorsakerna globalt. En hjärtstimulator vars funktion är att stimulera hjärtat till att återgå till en normal hjärtfrekvens. Personer som lever med en implanterbar hjärtstimulator upplever rädsla, oro och ångest relaterat till vardagen då man fruktar för elektriska störningar eller enhetsfel. En personcentrerad omvårdnad är viktig då det underlättar för patienter att leva ett normalt liv som möjligt.Syftet: Syftet med litteraturstudien var att belysa omvårdnadsbehov i form av stöd hos patienter som lever med implanterbar hjärtstimulator. Metod: En litteraturstudie med induktiv ansats och kritisk granskning av 11 artiklar. Resultat: Resultatet delas in i tre teman: Iformation, socialt och professionellt stöd samt Kontinuerlig uppföljning. Information skapar större förståelse samt trygghet hos patienter. Stöd från omvårdnaspersonal och närstående ökade förmågan av sjävlkännedom och självskänsla. Kontinuerliga uppföljningar förbättrade fysiska och psykologiska faktorer, som ökade livskvaliteten. Slutsats: I studien framkom det att information, stöd och kontinuerliga uppföljningar var av stor betydelse för den personcentrerade omvårdnaden. Studien redogör att utterligare kunskaper behövs inom sjuksköterskeprofessionen för att berdiva en god vård- och omsorg. / Background: Today many people live with cardiovascular disease, especially cardiac arrhythmias and / or cardiac arrest, which is one of the most common causes of global death. A pacemakers function is to stimulate the heart to return to a normal heart rate. People who live with an implantable cardiac stimulator experience fear, concerns and anxiety related to electrical disturbances and device error in everyday life. Person-centered nursing is important as it makes it easier for patients to live a normal life as possible. Purpose/aim: The aim of the literature study was to highlight the nursing needs in the form of support in patients living with the implantable cardiac defibrillator. Method: A literature study using an inductive approach and 11 articles was critically reviewed. Result: The results are divided into three themes: Information, social and professional support and Continuous follow-up. Information created greater understanding and safety for the patient. Support from nursing staff and relatives increased the ability of self-awareness and self-esteem. Continuous follow-up improved physical and psychological factors that increased the quality of life. Conclusion: The findings of the study were that information, support and continuous follow up were of great importance concerning person-centered nursing. The study reports that additional knowledge is needed in the nursing profession to be able to conduct good care and nursing.

The aim of this diploma work is the suggestion and realization of a cardiostimulator of „On Demand“ type operated by microcontroller. The work is structured on four thematic parts. For the correct suggestion of the whole system, firstly is necessary to understand correctly the cell’s electrophysiology and heart’s anatomy, inclusive the cardiology arrhytmia, which are adherent to cardiostimulators. The cardiostimulator is inhibited by the R-wave and is adaptive on a pulse rate of a source signal. The whole system is supplied by batteries and this supplying is taken into consideration. The network’s functionality is realized on the ECG simulator. There are suggested the suitable enhancements in discussion.

Implanting of leadless pacemakers is an innovative alternative to conventional implants. Of important benefit for patients is the minimally invasive approach, the minimalisation of risk of infection in the system and the reduced impact on quality of life when compared with conventional implants. The aim of this work is to review how patients rate their quality of life pre and post implant of the leadless pacemaker. For our research, we opted for a qualitative research method in the form of a standardized questionnaire about the Leadless pacemaker. The questionnaire survey will be conducted from December 2016 until the end of August 2017. The research sample consists of patients who were implanted with the Leadless pacemaker during a four-year period from December 2, 2012 to October 31, 2016 and who attend our hospital's cardiac pacemaker clinic. We would like to present the results obtained in a peer-reviewed journal and in professional cardiology conferences in the nursing section. We present one aspect of treatment (quality of life) at our institution, which has the largest number of implants of Leadless pacemakers in the Czech Republic. keywords: leadless pacemaker, nursing care, pacemaker implant, quality of life