Patients with ventricular pacemakers and pacemaker syndrome may need placement of an additional pacemaker lead. Hospitalize and monitor patients undergoing device or lead implantation for 24 hours after placement surgery.
Administer intravenous antibiotics (cefazolin, or vancomycin in patients with beta-lactam allergy) for prophylaxis against skin wound infections. Do not continue intravenous antibiotic therapy for more than 24 hours. If infection develops around the device, it is better detected early in the course in case device explantation is necessary.
Because diagnosis and treatment require interrogation and reprogramming of pacemaker, patients must be seen in either a clinical or hospital setting in which the appropriate interrogation equipment is available. Each pacemaker manufacturer produces an interrogation computer for its own devices. A major institution will have interrogation computers from several different manufacturers available for use.
Some pacemaker manufacturers provide courtesy interrogation services involving site visits for rural populations without easy access to functional facilities.
For ventricularly paced patients, addition of an atrial lead and institution of AV synchronous pacing usually resolves symptoms.
In patients with other pacing modes, symptoms usually resolve after interrogation and reprogramming of pacemaker parameters, such as AV delay, postventricular atrial refractory period, sensing level, and pacing threshold voltage. In many cases, optimal parameter values may be obtained experimentally with successive reprogramming and measurement of pertinent parameters, such as blood pressure, cardiac output (see the Cardiac Output calculator), and total peripheral resistance, as well as observations of symptomatology.
In rare instances, using hysteresis to help maintain AV synchrony can help alleviate symptoms in patients with VVI pacemakers and intact sinus node function. For example, if pacing rate is 60 beats per minute (bpm), the hysteresis rate can be programmed to be 50 bpm; in this way, pacing is not instituted until the native ventricular rate falls below 50 bpm, but when pacing is instituted, the pacemaker rate is 60 bpm. Hysteresis effects a reduction in the amount of time spent in pacing mode, which can alleviate symptoms, particularly when the pacing mode, such as VVI, is generating AV dyssynchrony.
Additional treatment modalities include replacing the pacemaker pulse generator and revision of medication regimen.
Medical care includes supportive care in relation to possible heart failure, hypotension, tachycardia, tachypnea, and oxygenation deficit.
Diet and Activity
A low-salt diet is indicated for patients with heart failure.
For patients with autonomic insufficiency, a high-salt diet may be appropriate.
For patients with dehydration, oral fluid rehydration is needed.
Patients may engage in activities as tolerated.
Consultation with an electrophysiologist determines the possible need for additional pacemaker lead placement and the care related to the pacemaker and for procedures to aid in diagnosis and treatment of pacemaker syndrome.
Because most cases of pacemaker syndrome occur in the setting of ventricular pacing, institute atrial pacing whenever it is not contraindicated. This includes AAI pacing for most cases of sinus node disease with intact AV nodal conduction. Alternatively, a dual-chamber system can be programmed to a long AV interval to promote intrinsic conduction, provided that the PR interval is not markedly prolonged.
Baseline studies by echocardiogram can assess change in cardiac output, stroke volume, and left atrial total emptying fraction in response to ventricular pacing. Examination of these parameters may guide the decision to institute dual-chamber pacing.
At the time of device implantation, optimize pacing parameters, such as AV delay, PVARP, and rate response slope, for physiologic timing of atrial and ventricular contractions.
Schedule follow-up visits after device or lead implantation as follows:
1-2 weeks for wound check
1 month for pacemaker interrogation
3 months for pacemaker interrogation
Every 6 months thereafter for pacemaker interrogation
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