CP1-Bradyarrhythmias-and-Pacemaker-Indications-2012.ppt

List the common symptoms of bradycardia

List and describe the two causes of bradycardia

Given an ECG rhythm, determine the bradyarrhythmia present

Describe the most common pacemaker indications – per the ACC/AHA/HRS 2008 Guidelines

Define the permanent pacemaker classifications of recommendations and level of evidence criteria

Describe the guidelines for choice of pacemaker generator �in selected indications for pacing

1. CorePace – Module #1
Bradyarrhythmias and
Pacemaker Indications

2. Disclosures
This presentation is provided for general educational
purposes only and should not be considered the exclusive
source for this type of information. At all times, it is the
professional responsibility of the practitioner to exercise
independent clinical judgment in a particular situation.
The device functionality and programming described in this
module are based on Medtronic products and can be
referenced in the device manuals.
Updated: April 2012

3. Objectives
•List the common symptoms of bradycardia
•List and describe the two causes of bradycardia
•Given an ECG rhythm, determine the bradyarrhythmia
present
•Describe the most common pacemaker indications – per
the ACC/AHA/HRS 2008 Guidelines
•Define the permanent pacemaker classifications of
recommendations and level of evidence criteria
•Describe the guidelines for choice of pacemaker generator
in selected indications for pacing

4. How to identify...
•Symptoms: subjective sensations (e.g. Pain, nausea,
dizziness, palpitations).
•Signs: objective or physical manifestations (e.g. Jugular
distension, cardiac murmur, fever).
•Syndrome: group of signs and symptoms that might have
different causes (e.g. Febrile syndrome, anemic
syndrome).
•Disease: has particular characteristics and in general has
a specific cause.

5. Symptom Basis
Bradycardia
/asystole

 cardiac output

 perfusion

Symptoms
AV dyssnchrony

 venous pressures

‘Pacemaker
Syndrome’

Symptoms
CO
2
O
2
O
2
CO
2
CO
2
O
2
O
2
CO
2

6. Symptoms of Bradycardia
•Usually occurs when heart is not pumping enough blood to
meet body's needs. This often happens when the heart
rate is very slow or remains slow for a long period of time.
•Related to organ hypo-perfusion and include:
–Dizziness or lightheadedness
–Fainting (syncope) or near-fainting
–Tiredness (fatigue)
–Shortness of breath
–Palpitations
–Chest pain (angina)
–Increased difficulty exercising
–Confusion or difficulty concentrating
–Some people with bradycardia do not have symptoms
Yan, Gan-Xin (2011). Management of Cardiac Arrhythmias. New York: Springer Science. pg.
307.
 

7. Classifications of Bradyarrhythmias
•There are two types of bradyarrhythmias
–Those related to problems with impulse formation
–Those related to problems with impulse conduction
Sinus node
AV node

8. Classification of Bradyarrhythmias
•Problems with Impulse Formation
–Sinus Arrest
–Sinus Bradycardia
–Chronotropic Incompetence
–Brady/Tachy syndrome

9. Sinus Arrest
•Failure of sinus node discharge
•Absence of atrial depolarization
•Periods of ventricular asystole
•May be episodic as in vaso-vagal syncope, or carotid sinus
hypersensitivity
–May require a pacemaker

10. Sinus Bradycardia
•Sinus Node depolarizes very slowly
•If the patient is symptomatic and the rhythm is persistent
and irreversible, may require a pacemaker

11. Chronotropic Incompetence
The heart rate is unable to change in
response to the body’s metabolic demand.
Griffen, Brian P. (2011). Manual of Cardiovascular Medicine. Philadelphia: Lippincott,
Williams, and Wilkins. (pg. 79). 

12. Brady/Tachy Syndrome
•Intermittent episodes of slow and fast rates from the SA node
or atria
•Brady < 60 bpm
•Tachy > 100 bpm
•AKA: Sinus Node Disease
–Patient may also have periods of AF and chronotropic incompetence
–Most common pacing indication
Curtis, Anne B. (2011). Fundamentals of Cardiac Pacing. Massachusetts: John and Bartlett
Publishers. (pg. 24). 

13. Bradycardia Classifications
•Problems with Impulse Conduction
–Exit Block
–First Degree AV block
–Second Degree AV block
•Mobitz Type 1 – Wenckebach
•Mobitz Type 2
–Third Degree AV block – Complete heart block
–Bifasicular/Trifasicular block

14. Exit Block
•Transient block of impulses from the SA node
–Sinus Wenckebach is possible, but rare
•Pacing is rare unless symptomatic, irreversible, and
persistent

15. First-Degree AV Block
•PR interval > 200 ms
•Delayed conduction through the AV Node
-Example shows PR Interval = 320 ms
-Not an indication for pacing
-Some consider this a normal variant (not an arrhythmia)

16. Second-Degree AV Block – Mobitz I
•Progressive prolongation of the PR interval until there is
failure to conduct and a ventricular beat is dropped
•Otherwise known as Wenckebach block
–Usually not an indication for pacing

17. Second-Degree AV Block – Mobitz II
•Regularly dropped ventricular beats
–2:1 block (2 P-waves for every 1 QRS complex)
–Atrial rate = 75 bpm, Ventricular rate = 42 bpm
•A “high grade” block, usually an indication for pacing
–May progress to third-degree, or Complete Heart block (CHB)

18. Third-Degree AV Block
Complete Heart Block
•No impulse conduction from the atria to the ventricles
–Atrial rate = 130 bpm, Ventricular rate = 37 bpm
–Complete A – V disassociation
–Usually a wide QRS as ventricular rate is idioventricular

19. Fascicular Block
Right bundle branch block
and left anterior hemiblock
Right bundle branch
block and left
posterior hemiblock
Complete left bundle
branch block

20. Trifascicular Block
•Complete block in the right bundle branch, and
•Complete or incomplete block in both divisions of the left
bundle branch
•Identified by EP Study

21. Knowledge Checkpoint
Name the two root causes of bradyarrhythmias.

22. Knowledge Checkpoint
Name the bradyarrhythmia.

23. Knowledge Checkpoint
Name the bradyarrhythmia.

24. Pacemaker Indications
•Are dictated by industry accepted guidelines
•Established from peer reviewed publically accepted
clinical studies

25. Class I

Benefit >>> Risk
Procedure/
Treatment SHOULD
be performed/
administered
Class IIa

Benefit >> Risk
Additional studies with
focused objectives
needed
IT IS REASONABLE to
perform procedure/
administer treatment
Class IIb

Benefit ≥ Risk
Additional studies with
broad objectives
needed; Additional
registry data would be
helpful
Procedure/Treatment
MAY BE CONSIDERED
Class III

Risk ≥ Benefit
No additional studies
needed
Procedure/Treatment
should NOT be
performed/administered
SINCE IT IS NOT
HELPFUL AND MAY
BE HARMFUL
Level A: Data derived from multiple randomized clinical trials or meta-analyses
Multiple populations evaluated;
Level B: Data derived from a single randomized trial or nonrandomized studies
Limited populations evaluated;
Level C: Only consensus of experts opinion, case studies, or standard of care

Very limited populations evaluated
Classification of Recommendations
and Level of Evidence
Level of Evidence:

26. Common Pacing Indications
•The AHA and ACC have defined the indications for pacing
based on the underlying arrhythmia
•At its simplest patients with the following conditions are
commonly indicated for a pacemaker:
–Symptomatic bradycardia
–Sinus Node Disease (SND), or Sick Sinus Syndrome
–Complete Heart Block
–Chronotropic Incompetence
•Usually excludes “low grade” blocks (Mobitz I and 1
st

degree)
Epstein et al. “ACC/AHA/HRS Guidelines for Device-Based Therapy.” JACC Vol. 51, No. 21, 2008.

27. Sinus Node Dysfunction
Permanent pacemaker implantation is indicated for sinus
node dysfunction (SND) with documented symptomatic
bradycardia, including frequent sinus pauses that
produce symptoms.
Permanent pacemaker implantation is indicated for
symptomatic chronotropic incompetence.
Permanent pacemaker implantation is indicated for
symptomatic sinus bradycardia that results from required
drug therapy for medical conditions.
IIIaIIbIII
IIIaIIbIII
IIIaIIbIII

28. Sinus Node Dysfunction (cont’d)
Permanent pacemaker implantation is reasonable for SND with
heart rate less than 40 bpm when a clear association between
significant symptoms consistent with bradycardia and the
actual presence of bradycardia has not been documented.
Permanent pacemaker implantation is reasonable for syncope
of unexplained origin when clinically significant abnormalities of
sinus node function are discovered or provoked in
electrophysiological studies.

Permanent pacemaker implantation may be considered in
minimally symptomatic patients with chronic heart rate less
than 40 bpm while awake.
IIIaIIbIII
IIIaIIbIII
IIIaIIbIII

29. Sinus Node Dysfunction (cont’d)
Permanent pacemaker implantation is not indicated for
SND in asymptomatic patients.
Permanent pacemaker implantation is not indicated for
SND in patients for whom the symptoms suggestive of
bradycardia have been clearly documented to occur in the
absence of bradycardia.
Permanent pacemaker implantation is not indicated for
SND with symptomatic bradycardia due to nonessential
drug therapy.
IIIaIIbIII
IIIaIIbIII
IIIaIIbIII

30. Acquired Atrioventricular Blocks
in Adults
Permanent pacemaker implantation is indicated for third-
degree and advanced second-degree atrioventricular (AV)
block at any anatomic level associated with bradycardia
with symptoms (including heart failure) or ventricular
arrhythmias presumed to be due to AV block.
Permanent pacemaker implantation is indicated for third-
degree and advanced second-degree AV block at any
anatomic level associated with arrhythmias and other
medical conditions that require drug therapy that results in
symptomatic bradycardia.
IIIaIIbIII
IIIaIIbIII

31. Acquired Atrioventricular Blocks
in Adults (cont’d)
Permanent pacemaker implantation is indicated for third-
degree and advanced second-degree AV block at any
anatomic level in awake, symptom-free patients in sinus
rhythm, with documented periods of asystole greater than
or equal to 3.0 seconds or any escape rate less than 40
bpm, or with an escape rhythm that is below the AV node.
Permanent pacemaker implantation is indicated for third-
degree and advanced second-degree AV block at any
anatomic level in awake, symptom-free patients with atrial
fibrillation (AF) and bradycardia with 1 or more pauses of at
least 5 seconds or longer.
IIIaIIbIII
IIIaIIbIII

32. Acquired Atrioventricular Blocks
in Adults (cont’d)
Permanent pacemaker implantation is indicated for third-
degree and advanced second-degree AV block at any
anatomic level after catheter ablation of the AV junction.
Permanent pacemaker implantation is indicated for third-
degree and advanced second-degree AV block at any
anatomic level associated with postoperative AV block that
is not expected to resolve after cardiac surgery.
IIIaIIbIII
IIIaIIbIII

33. Acquired Atrioventricular Blocks
in Adults (cont’d)
Permanent pacemaker implantation is indicated for third-
degree and advanced second-degree AV block at any
anatomic level associated with neuromuscular diseases
with AV block, such as myotonic muscular dystrophy,
Kearns-Sayre syndrome, Erbs dystrophy (limb-girdle
muscular dystrophy), and peroneal muscular atrophy, with
or without symptoms.
Permanent pacemaker implantation is indicated for second-
degree AV block with associated symptomatic bradycardia
regardless of type or site of block.
IIIaIIbIII
IIIaIIbIII

34. Acquired Atrioventricular Blocks
in Adults (cont’d)
Permanent pacemaker implantation is indicated for
asymptomatic persistent third-degree AV block at any
anatomic site with average awake ventricular rates of 40
bpm or faster if cardiomegaly or left ventricular (LV)
dysfunction is present or if the site of block is below the AV
node.
Permanent pacemaker implantation is indicated for second-
or third-degree AV block during exercise in the absence of
myocardial ischemia.
IIIaIIbIII
IIIaIIbIII

35. Acquired Atrioventricular Blocks
in Adults (cont’d)
Permanent pacemaker implantation is reasonable for
persistent third-degree AV block with an escape rate
greater than 40 bpm in asymptomatic adult patients
without cardiomegaly.
Permanent pacemaker implantation is reasonable for
asymptomatic second-degree AV block at intra- or infra-
His levels found at electrophysiological study.
Permanent pacemaker implantation is reasonable for first-
or second-degree AV block with symptoms similar to those
of pacemaker syndrome or hemodynamic compromise.
IIIaIIbIII
IIIaIIbIII
IIIaIIbIII

36. Acquired Atrioventricular Blocks
in Adults (cont’d)
Permanent pacemaker implantation is reasonable for
asymptomatic type II second-degree AV block with a
narrow QRS. When type II second-degree AV block
occurs with a wide QRS, including isolated right bundle-
branch block, pacing becomes a Class I
recommendation. (See Section 2.1.3, “Chronic
Bifascicular Block” of the full text guidelines.)
IIIaIIbIII

37. Acquired Atrioventricular Blocks
in Adults (cont’d)
Permanent pacemaker implantation may be considered
for neuromuscular diseases such as myotonic muscular
dystrophy, Erb dystrophy (limb-girdle muscular
dystrophy), and peroneal muscular atrophy with any
degree of AV block (including first-degree AV block),
with or without symptoms, because there may be
unpredictable progression of AV conduction disease.
Permanent pacemaker implantation may be considered
for AV block in the setting of drug use and/or drug
toxicity when the block is expected to recur even after
the drug is withdrawn.
IIIaIIbIII
IIIaIIbIII

38. Acquired Atrioventricular Blocks
in Adults (cont’d)
Permanent pacemaker implantation is not indicated for
asymptomatic first-degree AV block. (See Section 2.1.3,
“Chronic Bifascicular Block” of the full-text guidelines.)
Permanent pacemaker implantation is not indicated for
asymptomatic type I second-degree AV block at the supra-His
(AV node) level or that which is not known to be intra- or infra-
Hisian.
Permanent pacemaker implantation is not indicated for AV
block that is expected to resolve and is unlikely to recur (e.g.,
drug toxicity, Lyme disease, or transient increases in vagal
tone or during hypoxia in sleep apnea syndrome in the
absence of symptoms).
IIIaIIbIII
IIIaIIbIII
IIIaIIbIII

39. Chronic Bifascicular Block
Permanent pacemaker implantation is indicated for
advanced second-degree AV block or intermittent
third-degree AV block.
Permanent pacemaker implantation is indicated for
type II second-degree AV block.
Permanent pacemaker implantation is indicated for
alternating bundle-branch block.
IIIaIIbIII
IIIaIIbIII
IIIaIIbIII

40. Permanent pacemaker implantation is reasonable for
syncope not demonstrated to be due to AV block when
other likely causes have been excluded, specifically
ventricular tachycardia (VT).
Permanent pacemaker implantation is reasonable for an
incidental finding at electrophysiological study of a markedly
prolonged HV interval (greater than or equal to 100
milliseconds) in asymptomatic patients.
Permanent pacemaker implantation is reasonable for an
incidental finding at electrophysiological study of pacing-
induced infra-His block that is not physiological.
IIIaIIbIII
IIIaIIbIII
IIIaIIbIII
Chronic Bifascicular Block (cont’d)

41. Chronic Bifascicular Block (cont’d)
Permanent pacemaker implantation may be considered in
the setting of neuromuscular diseases such as myotonic
muscular dystrophy, Erb dystrophy (limb-girdle muscular
dystrophy), and peroneal muscular atrophy with bifascicular
block or any fascicular block, with or without symptoms.
Permanent pacemaker implantation is not indicated for
fascicular block without AV block or symptoms.
Permanent pacemaker implantation is not indicated for
fascicular block with first-degree AV block without
symptoms.
IIIaIIbIII
IIIaIIbIII
IIIaIIbIII

42. Hypersensitive CSS and
Neurocardiogenic Syncope
Permanent pacing is indicated for recurrent syncope
caused by spontaneously occurring carotid sinus
stimulation (CSS) and carotid sinus pressure that induces
ventricular asystole of more than 3 seconds.
Permanent pacing is reasonable for syncope without
clear, provocative events and with a hypersensitive
cardioinhibitory response of 3 seconds or longer.

Permanent pacing may be considered for significantly
symptomatic neurocardiogenic syncope associated with
bradycardia documented spontaneously or at the time of
tilt-table testing.
IIIaIIbIII
IIIaIIbIII
IIIaIIbIII

43. Hypersensitive CSS and
Neurocardiogenic Syncope (cont’d)
Permanent pacing is not indicated for a hypersensitive
cardioinhibitory response to carotid sinus stimulation
without symptoms or with vague symptoms.
Permanent pacing is not indicated for situational
vasovagal syncope in which avoidance behavior is
effective and preferred.
IIIaIIbIII
IIIaIIbIII

44. Pacing After Cardiac Transplantation
Permanent pacing is indicated for persistent inappropriate
or symptomatic bradycardia not expected to resolve and
for other Class I indications for permanent pacing.
Permanent pacing may be considered when relative
bradycardia is prolonged or recurrent, which limits
rehabilitation or discharge after postoperative recovery
from cardiac transplantation.
Permanent pacing may be considered for syncope after
cardiac transplantation even when bradyarrhythmia has
not been documented.
IIIaIIbIII
IIIaIIbIII
IIIaIIbIII

45. Guidelines for Choice of Pacemaker Generator
in Selected Indications for Pacing
Pacemaker
Generator Type
Sinus Node
Dysfunction
AV Block
Neurally Mediated
Syncope or Carotid
Sinus Hypersensitivity
Single-chamber
atrial pacemaker
No suspected
abnormality of AV
conduction and not at
increased risk for future
AV block
Not appropriate Not appropriate
Maintenance of AV
synchrony during
pacing not necessary
Not appropriate Not appropriate
Single-chamber
ventricular
pacemaker
Maintenance of AV
synchrony during
pacing desired
Chronic atrial fibrillation
or other atrial
tachyarrhythmia or
maintenance of AV
synchrony during
pacing not necessary
Chronic atrial fibrillation or
other atrial tachyarrhythmia
Epstein A, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm
Abnormalities. J Am Coll Cardiol 2008; 51:e1–62. Table 2.
(Table continues on next slide)

46. Pacemaker
Generator Type
Sinus Node
Dysfunction
AV Block
Neurally Mediated
Syncope or Carotid
Sinus Hypersensitivity
Dual-chamber
pacemaker
AV synchrony during
pacing desired
Rate response
available if desired
Sinus mechanism present
Suspected abnormality
of AV conduction or
increased risk for future
AV block
AV synchrony during
pacing desired
Suspected abnormality of AV
conduction or increased risk
for future AV block
Rate response
available if desired
Rate response
available if desired
Single-lead,
atrial-sensing
ventricular
pacemaker
Not appropriate
Desire to limit the
number of pacemaker
leads
Not appropriate
Guidelines for Choice of Pacemaker Generator
in Selected Indications for Pacing
Epstein A, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of Cardiac Rhythm
Abnormalities. J Am Coll Cardiol 2008; 51:e1–62. Table 2.

47. Selection of Pacemaker Systems
for Patients With AV Block
Epstein A, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of
Cardiac Rhythm Abnormalities. J Am Coll Cardiol 2008; 51:e1–62. Figure 1.
AV block
AV
Synchrony
?
Rate
Response?
No Yes
Rate
Response?
No
Atrial
Pacing?
Yes
Ventricular
pacemaker
Rate-responsive
ventricular pacemaker
No Yes
Single-lead
atrial sensing
ventricular
pacemaker
Rate
Response?
Dual-
chamber
pacemaker
Rate-responsive dual-
chamber pacemaker
No
Yes
No Yes
Ventricular
pacemaker
Rate-responsive
ventricular
pacemaker
No Yes
Chronic atrial tachyarrhythmia,
reversion to sinus rhythm not
anticipated

48. YesNo
Sinus Node
Dysfunction
No
Atrial
pacemaker
Rate-responsive
atrial
pacemaker
Rate-responsive
dual-chamber
pacemaker
Dual-
chamber
pacemaker
Ventricular
pacemaker
Rate-responsive
ventricular
pacemaker
Yes
No
Yes
No Yes
No Yes
Selection of Pacemaker Systems
for Patients With SND
Epstein A, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based Therapy of
Cardiac Rhythm Abnormalities. J Am Coll Cardiol 2008; 51:e1–62. Figure 2.
Evidence for impaired
AV conduction or
concern over future
development of AV
block
Desire for
rate
response
Desire for AV
synchrony
Desire
for
rate
respons
e
Desire for
rate
response

49. Knowledge Checkpoint
Name the four most common pacemaker indications.

50. Knowledge Checkpoint
Permanent pacing is _______________ for situational
vasovagal syncope in which avoidance behavior is effective
and preferred.
Indicated? or Not Indicated?

51. Knowledge Checkpoint
Permanent pacemaker implantation is ______________
for sinus node dysfunction (SND) with documented
symptomatic bradycardia, including frequent sinus pauses
that produce symptoms.
Indicated? or Not Indicated?

52. Knowledge Checkpoint
Permanent pacemaker implantation is _____________ for
symptomatic chronotropic incompetence.
Indicated? or Not Indicated?

53. Key Learning Points
•Bradycardia typically occurs when the heart is not
pumping enough blood to meet the body's needs.
•There are two causes of bradycardia: when there is a
problem with impulse formation and when there is a
problem with impulse formation
•There are four classes of implant indications: Class I, IIa,
IIb and III. These indications are supported by 3 levels of
evidence: Level A, Level B and Level C.
•Generally Class I and IIa indications recommend that a
procedure or treatment should be applied.

54. Brief Statement: IPGs and ICDs
Indications
•Implantable Pulse Generators (IPGs) are indicated for rate adaptive pacing in patients who may
benefit from increased pacing rates concurrent with increases in activity and increases in activity
and/or minute ventilation. Pacemakers are also indicated for dual chamber and atrial tracking modes
in patients who may benefit from maintenance of AV synchrony. Dual chamber modes are
specifically indicated for treatment of conduction disorders that require restoration of both rate and
AV synchrony, which include various degrees of AV block to maintain the atrial contribution to cardiac
output and VVI intolerance (e.g. pacemaker syndrome) in the presence of persistent sinus rhythm.
•Implantable cardioverter defibrillators (ICDs) are indicated for ventricular antitachycardia pacing
and ventricular defibrillation for automated treatment of life-threatening ventricular arrhythmias.
•Cardiac Resynchronization Therapy (CRT) ICDs are indicated for ventricular antitachycardia
pacing and ventricular defibrillation for automated treatment of life-threatening ventricular arrhythmias
and for the reduction of the symptoms of moderate to severe heart failure (NYHA Functional Class III
or IV) in those patients who remain symptomatic despite stable, optimal medical therapy and have a
left ventricular ejection fraction less than or equal to 35% and a prolonged QRS duration.
•CRT IPGs are indicated for the reduction of the symptoms of moderate to severe heart failure (NYHA
Functional Class III or IV) in those patients who remain symptomatic despite stable, optimal medical
therapy, and have a left ventricular ejection fraction less than or equal to 35% and a prolonged QRS
duration.

55. Brief Statement: IPGs and ICDs
Contraindications
•IPGs and CRT IPGs are contraindicated for dual chamber atrial pacing in patients with chronic
refractory atrial tachyarrhythmias; asynchronous pacing in the presence (or likelihood) of
competitive paced and intrinsic rhythms; unipolar pacing for patients with an implanted cardioverter
defibrillator because it may cause unwanted delivery or inhibition of ICD therapy; and certain IPGs
are contraindicated for use with epicardial leads and with abdominal implantation.
•ICDs and CRT ICDs are contraindicated in patients whose ventricular tachyarrhythmias may have
transient or reversible causes, patients with incessant VT or VF, and for patients who have a
unipolar pacemaker.
Warnings/Precautions
•Changes in a patient’s disease and/or medications may alter the efficacy of the device’s
programmed parameters. Patients should avoid sources of magnetic and electromagnetic radiation
to avoid possible underdetection, inappropriate sensing and/or therapy delivery, tissue damage,
induction of an arrhythmia, device electrical reset or device damage. Do not place transthoracic
defibrillation paddles directly over the device. Additionally, for CRT ICDs and CRT IPGs, certain
programming and device operations may not provide cardiac resynchronization. Also for CRT
IPGs, Elective Replacement Indicator (ERI) results in the device switching to VVI pacing at 65 ppm.
In this mode, patients may experience loss of cardiac resynchronization therapy and / or loss of AV
synchrony. For this reason, the device should be replaced prior to ERI being set.

56. Brief Statement: IPGs and ICDs
Potential Complications
•Potential complications include, but are not limited to, rejection phenomena, erosion through the
skin, muscle or nerve stimulation, oversensing, failure to detect and/or terminate arrhythmia
episodes, and surgical complications such as hematoma, infection, inflammation, and
thrombosis. An additional complication for ICDs and CRT ICDs is the acceleration of ventricular
tachycardia.
See the device manual for detailed information regarding the implant
procedure, indications, contraindications, warnings, precautions, and
potential complications/adverse events. For further information, please call
Medtronic at 1-800-328-2518 and/or consult Medtronic’s website at
www.medtronic.com.
Caution: Federal law (USA) restricts these devices to sale
by or on the order of a physician.

57. World Headquarters Contact Information
©Medtronic, Inc. 2012
Minneapolis, MN
http://www.medtronic.com
All Rights Reserved
April 2012
World Headquarters
Medtronic, Inc.
710 Medtronic Parkway
Minneapolis, MN 55432-5604
USA
Tel: [phone]
Fax: [phone]
www.medtronic.com
Medtronic USA, Inc.
Toll-free: 1(800) 328-2518
(24-hour technical support for
physicians and medical
professionals)