Rate - Interval Conversion Table Rate Cycle length Rate Cycle length (BPM) (ms) (BPM) (ms) 20 3000 215 279 25 2400 220 273 30 2000 225 267 35 1714 230 261 40 1500 235 255 45 1333 240 250 50 1200 245 245 55 1091 250 240 60 1000 255 235 65 923 260 231 70 857 265 226 75 800 270 222 80 750 275 218 85 706 280 214 90 667 285 211 95 632 290 207 100 600 295 203 105 571 300 200 110 545 305 197 115 522 310 194 120 500 315 190 125 480 320 188 130 462 325 185 135 444 330 182 140 429 335 179 145 414 340 176 150 400 345 174 155 387 350 171 160 375 355 169 165 364 360 167 170 353 365 164 175 343 370 162 180 333 375 160 185 324 380 158 190 316 385 156 195 308 390 154 200 300 395 152 205 293 400 150 210 286 60,000 Rate (BPM or min1) = Cycle length (ms) 60,000 Cycle length (ms) = Rate (BPM or min1) W. Fischer • Ph. Ritter, Cardiac Pacing in Clinical Practice Springer-Verlag Berlin Heidelberg GmbH W. Fischer • Ph. Ritter Cardiac Pacing in Clinical Practice With a Foreword by D. Hayes With 324 Figures in 547 Parts, 8 Tables, and Glossary Springer Dr. med. Wilhelm Fischer Innere Abteilung, Krankenhaus Peißenberg Hauptstraße 55-57, D-82380 Peißenberg Dr. med. Philippe Ritter Dept. de Stimulation Cardiaque d'Electrophysiologie Centre Chirurgical Val d'Or, F-92210 Saint Cloud Translator: Rodolphe Ruffy Translation of the Second German Edition 1997, and of the French Edition 1997 W. Fischer, Ph. Ritter: Praxis der Herzschrittmacher-Therapie 2. Auflage 1997, ISBN 3-540-60264-X Ph. Ritter, W. Fischer: Pratique de la Stimulation cardiaque, Edition 1997 ISBN 978-3-642-63741-4 Library of Congress Cataloging-in-Publication Data Fischer, Wilhelm. 1949- [Praxis der Herzschrittmachertherapie. English] Cardiac pacing in clinical practice / W. Fischer, Ph. Ritter; with a foreword by David Hayes ; [translator, Rodolphe Ruffy]. -- ist ed. p. cm. "Translation of the second German edition 1997" - T.p. verso Includes bibliographical references and index. ISBN 978-3-642-63741-4 ISBN 978-3-642-58810-5 (eBook) DOI 10.1007/978-3-642-58810-5 1. Cardiac pacing. I. Ritter, Ph., 1949- . II. Title. [DNLM: 1. Pacemaker, Artificial. 2. Car diac Pacing, Artificial. WG 26 F529P 1998a] RC684.P3F5513 1998 617.4 120645--dcZT DNLM/DLC for Library of Congress 98-12136 CiP This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illus trations, recitation, broadcasting, reproduction on microfilm or in other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9,1965, in its current version, and permission for use must always be obtained from Springer-Verlag. Violations are liable for prosecution under the German Copyright Law. © Springer-Verlag Berlin Heidelberg 1998 Originally published by Springer-Verlag Berlin Heidelberg New York in 1998 The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publisher cannot assume any legal responsibility for given data, especially as far as directions for the use and the handling of chemicals and technical devices are concerned. This information can be obtained from the instructions on safe laboratory practice and from the manufacturers of chemical and laboratory equipment. Cover Design: E Steinen-Broo, eSTUDIO CALAMAR, E-17494 Pau Typesetting: FotoSatz Pfeifer GmbH, D-82166 Gräfelfing SPIN: 10769266 22/3111 - 5 4 3 2 1 - Printed on acid-free paper Dedicated to our families Foreword Pacemaker technology has evolved rapidly over the nearly 40 year history of the device. On several occasions over the past decade, I have heard individuals involved in some aspect of cardiac pacing, state that pacemaker technology had reached the end of it's developmental stage and no further improvements should be anticipated. Conversely, I've also heard many far-sighted individuals discuss potential pacemaker features and applications that seemed far-fetched. The lat ter group have been vindicated as pacemaker technology continues to advance. In such a dynamic field, it is crucial that state-of-the-art information exists and that it is provided in an understandable format. In the course of our medical library acquisitions, many of us have purchased a medical textbook based upon the title that promises "state-of-the-art" infor mation, only to be disappointed when the text fails to adequately deliver the expected information. Anyone who reads "Cardiac Pacing in Clinical Practice<~ whether cover-to-cover or used as a reference for management of clinical pacing problems, will find that the text fulfills all expectations. Drs. Ritter and Fischer have provided a comprehensive, understandable, state-of-the-art guide to clini cal management of the pacemaker patient that can be appreciated by both physi cian and allied professional. Preparation of such a comprehensive text by only two authors is an arduous task. However, the benefits of limited authorship is evident as one reads this book. There is a consistent style throughout in both text and graphics. This avoids redundancy and facilitates comprehension. In addition, the consistent writing style allows the authors to build on complexity from the beginning to end of each chapter. For example, the description of pacemaker system implan tation encompasses the most basic portions, such as attaching the lead to the pulse generator, as well as less commonly encountered aspects such as pace maker implantation in the cardiac transplant patient. The extensive clinical experience of the authors is clearly evident. Every chap ter is complete and up-to-date, from the description of the newer combipolar pacing configuration to new indications for pacing, and the extensive glossary and index makes it easy to seek answers to specific clinical questions. Readers who are involved in the day-to-day care of the pacemaker patient will find sev eral chapters particularly helpful. The extensive discussion of pacing modes and their application allows a logical approach to individualizing pacemaker pre- VIII Foreword scriptions. An exhaustive guide to patient follow-up and programming is pro vided. Thorough knowledge and understanding of this text should allow provid ers to avoid complications in their practice. However, in the event that a patient with a complication is referred for treatment, practical management guidelines for everything from hematoma formation to AccufixTM lead management is included. It is highly likely that this text will prove to be an enduring source of informa tion in the field of cardiac pacing, providing an inclusive guide with an interna tional perspective. Those of us dedicated to providing expert care in the arena of cardiac pacing, are hopeful that many countries will eventually develop and apply standards of care for the paced patient. Ritter and Fischer provide a work that could serve as a basis for such standards. David L. Hayes, MD Acknowledgements This book is the result of an intensive collaboration between scientists, engi neers, and physicians from separate institutions, cities, countries, and conti nents. Ms. Monika Schrimpf of Springer-Verlag deserves a great deal of credit for her assistance and organization and Ms. Ursula Appl, Dipl.-Ing., for the excellent and expert translation she provided the authors with. Furthermore, we gratefully acknowledge the invaluable assistance of Prof. Werner Irnich; both his counsel and his review of the whole book with regard to its physics and correct use of terminology are much appreciated. We owe many thanks to Ulf H. Knabe, MD, for his helpful input and proof reading of the sections on surgery and to Martin R. Locher for his valuable edito rial contributions to the German edition during its extensive revision. Thanks are also due to Kaoru Kunisada, MD, Japan, for his fine cooperative efforts. Special thanks also go to Bernard Dodinot, MD, Editor in Chief of Stimucoeur Stimulography, for giving us permission to reproduce a great number of the fig ures included in this book; to Rodolfo Ruffy, MD, Cardioscript International, for the very professional translation of this book from the German and French, and for his corrections and advice; to David Hayes, MD, for kindly writing the fore word; and to Jacques Mugica, MD, and Prof. Claude Daubert, MD, for their great help in making this work possible. Philippe Ritter Wilhelm Fischer st. Cloud Peissenberg Contents Introduction: A Short History of Cardiac Pacing. . . . . . . . . . . . . . . . . . . . . . 1 1 Brief Review of the Anatomy, Electrophysiology and Pathophysiology of the Cardiac Conduction System 1.1 Anatomy and Electrophysiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 The Sinoatrial Node .............................................. 5 The Atrioventricular Node. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 The His Bundle .................................................. 7 The Purkinje Network. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Automatic Foci. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Anterograde and Retrograde Conduction ............................ 8 Refractory Periods of the Heart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 The Absolute Refractory Period .................................. 9 The Relative Refractory Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Refractory Periods in Various Cardiac Tissues . . . . . . . . . . . . . . . . . . . . .. 10 1.2 The Main Depolarization and Conduction Disorders. . . . . . . . . . . . . . . 11 Sinus Node Disease (the Sick Sinus Syndrome) . . . . . . . . . . . . . . . . . . . . . . . . 11 Chronotropic Incompetence ..................................... 11 Atrial Tachyarrhythmias ........................................ 11 Electrophysiological Testing ..................................... 11 Atrioventricular and Intraventricular Conduction Disorders ............ 14 Atrioventricular Block (AVB) .................................... 14 Bundle Branch Blocks .......................................... 16 2 General Technical Concepts 2.1 How to Stimulate the Heart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 19 Basic Principles of Electricity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 20 Pacing Threshold. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 21 Influence of Pacing Rate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 24 Influence of Drugs and Metabolic Disorders. . . . . . . . . . . . . . . . . . . . . . .. 25 Influence of Degree of Fibrosis ................................... 25 Influence of Electrode Configuration on Pacing Impedance and Pacing Threshold. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 25