Title page	5
	Copyright page	6
	Contents	7
	Contributors	9
	Preface	11
	1: Pacing and Defibrillation: Clinically Relevant Basics for Practice	13
	Anatomy and physiology of the cardiac conduction system	14
	Electrophysiology of myocardial stimulation	14
	Pacing basics	16
	Stimulation threshold	16
	Variations in stimulation threshold	18
	Sensing	19
	Lead design	21
	Bipolar and unipolar pacing and sensing	25
	Left ventricular leads	25
	Pulse generators	26
	Pacemaker nomenclature	28
	Defibrillation basics	28
	Critical mass	30
	Upper limit of vulnerability	30
	Progressive depolarization	31
	Virtual electrode depolarization	31
	Defibrillation theory summary	33
	The importance of waveform	33
	Biphasic waveforms	34
	Phase duration and tilt	35
	Polarity and biphasic waveforms	36
	Mechanism of improved efficacy with biphasic waveforms	36
	Measuring shock dose	36
	Measuring the efficacy of defibrillation	37
	Threshold and dose–response curve	37
	Relationship between defibrillation threshold and dose–response curve	37
	Patient-specific defibrillation threshold and safety margin testing	38
	Clinical role of defibrillation testing at implantation	39
	Management of the patient who fails defibrillation testing	41
	Upper limit of vulnerability to assess safety margin	45
	Drugs and defibrillators	45
	Antitachycardia pacing	46
	References	47
	2: Hemodynamics of Cardiac Pacing: Optimization and Programming to Enhance Cardiac Function	53
	Cardiovascular physiology	54
	Abnormal physiology	55
	Basics of hemodynamic pacing	55
	Chronotropic response	55
	Atrioventricular dissociation and ventriculoatrial conduction	55
	Atrioventricular synchrony	57
	Atrioventricular optimization	61
	Principles of echocardiographic atrioventricular optimization	64
	Atrial mechanical function	68
	Effect of pacing mode on morbidity and mortality	68
	Optimal ventricular pacing sites	73
	Pacing in heart failure	78
	Influence of pacing site	78
	Mechanisms underlying the benefits of left ventricular and biventricular pacing	79
	Left ventricular diastolic function	82
	AV optimization in cardiac resynchronization therapy	82
	Ventricular timing optimization (V-V optimization)	83
	Optimizing site of pacing (LV and/or RV)	83
	Electrical parameters for V-V optimization	84
	QRS vector fusion	84
	Echocardiography for ventricular timing optimization	87
	Clinical approaches to V-V optimization	87
	Other end-points for optimization	89
	Right ventricular function	89
	Cardiac contractility modulation pacing	90
	Ventricular rate regulation	90
	Less common indications for pacing for hemodynamic improvement	90
	Pacing in hypertrophic obstructive cardiomyopathy	90
	Hemodynamic benefits of pacing in neurocardiogenic syndromes	91
	Hemodynamic benefits of pacing in first-degree atrioventricular block	92
	Conclusions	92
	Addendum	92
	References	92
	3: Indications for Pacemakers, ICDs and CRT: Identifying Patients Who Benefit from Cardiac Rhythm Devices	105
	Indications for permanent pacing	106
	Atrioventricular block	106
	Acute myocardial infarction	112
	Chronic bifascicular and trifascicular block	113
	Sinus node dysfunction	113
	Neurally mediated reflex syncope	116
	Tachyarrhythmias	118
	Hypertrophic cardiomyopathy	119
	Congestive heart failure	119
	Pacing after cardiac transplantation	124
	Indications for the implantable cardioverter-defibrillator	124
	Secondary prevention	125
	Primary prevention	125
	Contraindications to implantable cardioverter-defibrillator therapy	138
	Acknowledgement	139
	References	139
	4: Choosing the Device Generator and Leads: Matching the Device with the Patient	145
	Pacemaker selection	146
	Symptomatic bradycardia	147
	Pure sinus node dysfunction	148
	Pure atrioventricular block	148
	Neurocardiogenic syncope and carotid sinus hypersensitivity	148
	Choosing specific programmable options	148
	Choosing the rate-adaptive sensor	148
	Choosing the lead or leads	148
	Threshold reduction	149
	Lead polarity	149
	Electrode design	151
	Lead conductor	151
	Lead insulation	151
	Lead diameter	152
	Compatibility of lead and pulse generator	153
	Epicardial leads	153
	Resources for lead performance and survival data	154
	Generator and lead selection in defibrillators	156
	Lead design considerations for ICD leads	156
	Programmable waveforms	161
	Dual-chamber or single-chamber ICD?	161
	Factors favoring single-chamber defibrillators	161
	Factors favoring dual-chamber defibrillators	161
	Specific device and lead features influencing selection	162
	Conclusions	166
	References	166
	5: Implanting and Extracting Cardiac Devices: Technique and Avoiding Complications	169
	Implantation facility	170
	Anesthesia	170
	The pulse generator pocket	171
	Venous approaches	172
	Axillary (extrathoracic subclavian) approach	172
	Subclavian approach	177
	Cephalic approach	177
	Jugular approach	177
	Iliac vein approach	178
	Ventricular lead placement	178
	Coronary sinus lead placement	187
	Coronary sinus cannulation	188
	Coronary sinus venography	193
	Securing permanent leads	201
	Dual-chamber pulse generator implantation	201
	Measurement of pacing and sensing thresholds	204
	Determination of pacing threshold	205
	Determination of sensing threshold	206
	Epicardial systems	208
	Hardware adaptations	208
	Special considerations in pediatric patients	210
	Device implantation after cardiac transplantation	214
	Hospital stay after implantation	215
	Pulse generator replacement	215
	Post-implant order set	217
	Homegoing instructions	217
	Lead extraction	217
	Indications for lead extraction	217
	Facility requirements for lead extraction	221
	Outcomes of lead extraction	221
	Complications of lead extraction	221
	Extraction techniques	222
	References	227
	6: Implant-Related Complications: Relevant Anatomy and an Approach for Prevention	231
	Complications related directly to the implant procedure	232
	Lead dislodgement	232
	Pneumothorax	235
	Lead perforation	237
	Pericarditis	240
	Arrhythmias	240
	Pulse generator pocket complications	241
	Pain	242
	Inadvertent left ventricular lead placement	244
	Thrombosis	244
	Loose connector block connection	246
	Lead damage	246
	Infection	247
	Abandoned and nonfunctioning, noninfected leads	250
	Twiddler’s syndrome	252
	New symptoms secondary to pacemaker placement	257
	Extracardiac stimulation	257
	Pacemaker syndrome	257
	Tricuspid regurgitation	257
	Battery depletion	258
	Implant or hardware-related complications that may result in recurrence of preimplantation symptoms (see also Chapter 10: Troubleshooting)	258
	Loss of circuit integrity	258
	Lead fracture and insulation defect	260
	Exit block	260
	References	264
	7: Timing Cycles	267
	Basic approach	268
	Pacing modes	269
	Atrial inhibited pacing	269
	Single-chamber triggered-mode pacing	271
	Rate-modulated pacing	271
	Atrioventricular sequential, ventricular inhibited pacing (DVI)	273
	Atrioventricular sequential, non-P-synchronous pacing with dual-chamber sensing (DDI)	273
	Atrioventricular sequential, non-P-synchronous, rate-modulated pacing with dual-chamber sensing (DDIR)	274
	Atrial synchronous (P-tracking/P-synchronous) pacing (VDD)	274
	Dual-chamber pacing and sensing with inhibition and tracking (DDD)	274
	Portions of pacemaker timing cycles	276
	Atrioventricular interval	276
	Comparison of atrial with ventricular-based timing	280
	Dual-chamber rate-modulated pacemakers: effect on timing cycles	284
	Mode switching	288
	Avoiding atrial pace/sense competition	288
	Timing components of ventricular avoidance pacing algorithms	290
	Endless-loop tachycardia	291
	Timing cycles with algorithms responding to sudden bradycardia	292
	Timing cycles unique to biventricular pacing	293
	Timing cycles in ICDs	299
	Initial electrocardiographic interpretation	300
	Response to magnet application	301
	Single-chamber pacemakers	303
	Dual-chamber pacemakers	304
	Biventricular paced electrocardiogram: position, adequacy, and timing	308
	Characteristic electrocardiographic patterns with specific lead locations	311
	Timing intervals and the ECG	314
	Electrocardiographic considerations in the patient not responding to CRT	328
	Conclusions	328
	References	328
	8: Programming: Maximizing Benefit and Minimizing Morbidity Programming	331
	Programmers	332
	Pacemaker programming	332
	Interrogation	333
	Emergency programming	333
	Programmed parameters	333
	Measured data	334
	Specific programmable parameters to consider in all patients	334
	Unexpected programming	362
	Programming during routine follow-up	369
	Defibrillator programming	372
	Implantable cardioverter-defibrillator sensing	374
	Implantable cardioverter-defibrillator detection	378
	SVT-VT discriminators	385
	Ventricular therapies	402
	Atrial defibrillators: detection and therapies	405
	Optimizing programming	406
	Cardiac resynchronization programming	407
	Algorithms to promote continuous tracking	407
	Algorithms to manage premature ventricular complexes	410
	Algorithms to manage atrial fibrillation	411
	Device-based optimization for cardiac resynchronization	411
	Conclusions	412
	References	413
	9: Sensor Technology for Rate-Adaptive Pacing and Hemodynamic Optimization	419
	Indications for rate-adaptive pacing	420
	Sensors available for rate-adaptive pacing	420
	Activity sensors	421
	Minute ventilation sensors	423
	SonR sensor (previously called peak endocardial acceleration sensor)	423
	Right ventricular impedance-based sensor	424
	Stimulus-T or QT, sensing pacemaker	426
	Other sensors	426
	Dual-sensor rate-adaptive pacing	427
	Sensor applications for hemodynamic management	430
	Programming	430
	Programmable parameters	432
	Rate-adaptive pacing with cardiac resynchronization devices	436
	AV and V-V timing	436
	Future of rate-adaptive sensors	437
	References	437
	10: Troubleshooting: Interpreting Diagnostic Information to Ensure Appropriate Function	439
	Pacemaker troubleshooting	440
	Clinical assessment	440
	Identifying the pulse generator	441
	Electrocardiographic interpretation	442
	Lead integrity	442
	Pulse generators	444
	Clinical troubleshooting	444
	Diagnostic features	451
	Unexpected device failure	451
	Operative evaluation of pacing systems	452
	Focused troubleshooting	452
	Failure to capture	453
	Pseudo-malfunctions	464
	Failure to pace (no output)	466
	Undersensing	470
	Alteration in programmed pacing rate	474
	New symptoms after pacemaker implantation	476
	ICD troubleshooting	484
	Diagnostic tools for ICD troubleshooting	484
	Evaluating appropriateness of delivered therapy	488
	Determining if shocks for VT are necessary	518
	Approach to the patient with frequent shocks	522
	Unsuccessful shocks	523
	Failure to deliver or delayed therapy: underdetection and undersensing	527
	Troubleshooting ICD lead failure	533
	Troubleshooting cardiac resynchronization devices	545
	Failure to respond to resynchronization pacing	545
	Troubleshooting other problems in CRT systems	554
	References	558
	11: Radiography of Implantable Devices	565
	Introduction	566
	Pulse generators	566
	Other types of pulse generators	568
	Leads	570
	Pacemaker leads	572
	Transvenous atrial leads	576
	Transvenous ventricular leads	579
	Epicardial leads	584
	ICD leads	584
	Epicardial ICD leads	584
	Transvenous ICD leads	584
	Coronary venous leads	589
	Miscellaneous considerations	595
	Conclusions	597
	References	600
	12: Electromagnetic Interference: Sources, Recognition, and Management	603
	Pacemaker responses to noise	605
	Asynchronous pacing	605
	Mode resetting (power-on reset, or electrical reset)	609
	Environmental electromagnetic interference	610
	References	623
	13: Follow-up	625
	Requirements for a device follow-up clinic	626
	Space	626
	Personnel	626
	Equipment	627
	Pacemaker follow-up	628
	Trans-telephonic monitoring	628
	Equipment	628
	Trans-telephonic monitoring sequence	629
	Internet-based remote monitoring	630
	Pacemaker clinic follow-up visit	630
	ICD follow-up	638
	Assessment of the patient’s clinical status	638
	Pulse generator assessment	638
	Capacitor status	640
	Assessing lead function	642
	Defibrillation efficacy assessment	643
	Medications	644
	Strategies to minimize shocks	646
	CRT follow-up specifics	646
	Remote patient monitoring	646
	Medical advisories and recalls	652
	Lifestyle and personal concerns	656
	Psychologic issues encountered following device implantation	657
	Withdrawal of device support	658
	Conclusions	658
	References	658
	Index	663