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Kyung Hee Medical Center
Cardiology Division
심박동기, 제세동기, CRT삽입환자에서 보이는 심전도
경희의대 김진배
Kyung Hee Medical Center
Cardiology Division
Introduction
A pacemaker is really a
system that has two parts:
a small metal titanium can
containing the electronic
circuitry and a long-lasting
battery, called a pulse
generator and an insulated
wire, called a lead.
박동기란?
Kyung Hee Medical Center
Cardiology Division
Introduction
박동기 가 환자의 심박동을 감지하고 반응하는 양식으로 이러한 양식을 표현해 주는 기호가 존재한다.
환자의 심박동에 따라 조율 방식이 바뀌는 기능이 있는 심박동기가 존재한다.
조율 방식
Kyung Hee Medical Center
Cardiology Division
The NASPE/BPEG Generic (NBG) Code
Category Chamber(s) Paced
Chamber(s) Sensed
Response to Sensing
Programmability Rate Modulation
Antitachyarrhythmia Function(s)
Position I II III IV V
O = None
A = Atrium
V = Ventricle
D = Dual (A+V)
O = None
A = Atrium
V = Ventricle
D = Dual (A+V)
O = None
T = Triggered
I = Inhibited
D = Dual (T+I)
O = None
P = Simple Programmable
M = Multiprogrammable
C = Communicating
R = Rate Modulation
O = None
P = Pacing
(antitachyarrhythmia)
S = Shock
D = Dual (P+S)
Manufacturer’s Designation Only
S = Single (A or V)
S = Single (A or V)
Note: Positions I through III are used exclusively for antibradyarrhythmia function
Kyung Hee Medical Center
Cardiology Division
Common Pacemaker Modes
Pacing Sensing Response
to Sensing
Programmability
& Rate Response
V V I
- Ventricular pacing
- Ventricular sensing
- Inhibited when sensing a ventricular event
Kyung Hee Medical Center
Cardiology Division
Common Pacemaker Modes
Pacing Sensing Response
to Sensing
Programmability
& Rate Response
D D D
- Dual (Atrial & Ventricular) pacing
- Dual (Atrial & Ventricular) sensing
- Dual (Inhibited & Triggered) response to sensing
Kyung Hee Medical Center
Cardiology Division
Case
Kyung Hee Medical Center
Cardiology Division
QRS morphology Apex Vs Septal pacing
Kyung Hee Medical Center
Cardiology Division
Apex Vs Septal pacing
Kyung Hee Medical Center
Cardiology Division
Apex Vs Septal pacing
Kyung Hee Medical Center
Cardiology Division
ECG before pacemaker implantation
Kyung Hee Medical Center
Cardiology Division
83 M Hypertension
Syncope
Kyung Hee Medical Center
Cardiology Division
What is the mechanism of
bradycardia?
1. SA block
2. type II AV block with junctional escape rhythm
3. complete AV block with junctional escape rhythm
4. complete AV block with idioventricular escape rhythm
5. cannot be defined
정답: 3
Kyung Hee Medical Center
Cardiology Division
Rhythm strip after temporary pacemaker
VVI pacing
Kyung Hee Medical Center
Cardiology Division
Pacemaker Fusion and Pseudofusion
SAN
AVN
V
A
Cardiac pacemakers step by step 2004
Kyung Hee Medical Center
Cardiology Division
49 M s/p ICD implantation d/t Brugada SD
Chest discomfort ICD 삽입전
Kyung Hee Medical Center
Cardiology Division
ECG at OPD
2012-05-03
Kyung Hee Medical Center
Cardiology Division
ECG strip
2012-05-03
Kyung Hee Medical Center
Cardiology Division
What make the change of QRS
morphology ?
1. pseudo-fusion
2. fusion
3. spontaneous idioventricular rhythm
4. multiple PVC’s
5. Cannot be defined
정답: 2
Kyung Hee Medical Center
Cardiology Division
Telemetry monitoring
after mode change
2012-05-04
Kyung Hee Medical Center
Cardiology Division
What is the pacing mode ?
1. DDD VVI
2. VVI AAI
3. AAI VVI
4. DDD AAI
5. Cannot be defined
정답: 4
Kyung Hee Medical Center
Cardiology Division
63 F VVI with sick sinus syndrome
Both knee joint pain
Kyung Hee Medical Center
Cardiology Division
24hr Holter monitoring
Kyung Hee Medical Center
Cardiology Division
24hr Holter monitoring
Kyung Hee Medical Center
Cardiology Division
What is the mechanism of pacing
interval change ?
1. Sensing failure
2. Pacing failure
3. Oversensing
4. Hysteresis
5. Cannot be defined
정답: 4
Kyung Hee Medical Center
Cardiology Division
Hysteresis
환자의 자발적인 박동이 감지될 경우 escape interval을 길게 설정
Cardiac pacemakers step by step 2004
Kyung Hee Medical Center
Cardiology Division
65 F DDDR with complete AV block
Chest discomfort
Kyung Hee Medical Center
Cardiology Division
VVI 30 bpm
2012-05-04
Kyung Hee Medical Center
Cardiology Division
What is the mechanism of ST change ?
1. LVH with strain
2. Apical HCMP
3. Myocardial ischemia
4. Myocardial infarction
5. cannot be defined
정답: 5
Kyung Hee Medical Center
Cardiology Division
박동기 삽입전 심전도
2010-04-21
Kyung Hee Medical Center
Cardiology Division
Memory effect of myocardium
Sss
s
Sss Cardiac pacemakers step by step 2004
Kyung Hee Medical Center
Cardiology Division
70 M, s/p CAB
Stable angina, CAOD(3VD) Preop ECG
Kyung Hee Medical Center
Cardiology Division
Immediate postop
Kyung Hee Medical Center
Cardiology Division
Pacing with temporary pacemaker
What is the ECG finding ?
Kyung Hee Medical Center
Cardiology Division
Pacing with temporary pacemaker
Kyung Hee Medical Center
Cardiology Division
Mode change of pacemaker
AV sequential pacing VVI
Sensing failure pacemaker off
Kyung Hee Medical Center
Cardiology Division
ECG (POD#1)
Kyung Hee Medical Center
Cardiology Division
Sensing failure
Cardiac pacemakers step by step 2004
Kyung Hee Medical Center
Cardiology Division
ㅁㅁㅁ
ㅁㅁㅁ ㅁㅁㅁ
Cardiac pacemakers step by step 2004
Kyung Hee Medical Center
Cardiology Division
58 F DDD with complete AV block (’06)
Palpitation, chest discomfort
2012-02-22
Kyung Hee Medical Center
Cardiology Division
Medical history
2012-02-22
‘00, 본원에서 VVI implantation d/t tachybradycardia syndrome
‘02년부터 Follow up loss
’06년, OO 대 병원 심장내과 follow up 중 AV block발생 DDD로 upgrade
AF으로 Propafenon, digoxin, aspirin 복용하며 follow up중 증상 발현되어 본원 내원.
Kyung Hee Medical Center
Cardiology Division 2012-02-22
Chest PA and lateral
Kyung Hee Medical Center
Cardiology Division
What is the mechanism of wide QRS
tachycardia?
1. Ventricular tachycardia
2. SVT with aberrant conduction
3. sinus tachycardia with pacing rhythm
4. Use dependency
5. cannot be defined
정답: 5
Kyung Hee Medical Center
Cardiology Division
Pacemaker interrogation
2012-02-22
• Lower rate = 60 bpm
• Max tracking rate = 130 bpm
Kyung Hee Medical Center
Cardiology Division
Mode change
2012-02-22 DDD DDIR
Kyung Hee Medical Center
Cardiology Division
VVI 30 bpm
2012-02-22
Kyung Hee Medical Center
Cardiology Division
ECG on HD #2
2012-02-23
Kyung Hee Medical Center
Cardiology Division
70 F, CHF, Idiopathic DCMP (EF = 28%)
dyspnea Preop CRT
2011-11-16
Kyung Hee Medical Center
Cardiology Division
Chest PA and lateral after CRT-D
2011-11-17
Kyung Hee Medical Center
Cardiology Division
ECG after CRT-D
2011-11-17 QRS duration 150 120 ms
Kyung Hee Medical Center
Cardiology Division
ECG (VVI 30 bpm)
2012-05-04
Kyung Hee Medical Center
Cardiology Division
LV only pacing
2012-05-04
Kyung Hee Medical Center
Cardiology Division
RV only pacing
2012-05-04
Kyung Hee Medical Center
Cardiology Division
Take home massage !!
1.증상이 없더라도 규칙적으로 박동기 작동을 심전도로 확인하고 기록
2.환자의 history상 pacemaker indication확인
3. lead 위치를 chest x ray로 확인
4. pacing mode을 확인
5. 환자의 underlying rhythm을 확인
6. pacemaker interrogation하여 function확인
Kyung Hee Medical Center
Cardiology Division
Thank you for your attention !
도움 주신 분들
원주의대 안민수 선생님
힘찬 병원 이병호 선생님
경희대 윤명기 선생님
경희대 김상호 선생님
국군 수도 병원 김성순 선생님