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Heart Rhythm Devices

i n the ER. Heart Rhythm Devices. Soori Sivakumaran BASc MEng MD PEng FRCPC Medical Director, Heart Rhythm Device Clinic, Mazankowksi Alberta Heart Institute Associate Clinical Professor of Medicine University of Alberta. Devices are common. Chrysalis report 2011, MEDEC.

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Heart Rhythm Devices

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  1. in the ER Heart Rhythm Devices Soori Sivakumaran BAScMEng MD PEng FRCPC Medical Director, Heart Rhythm Device Clinic, Mazankowksi Alberta Heart Institute Associate Clinical Professor of Medicine University of Alberta

  2. Devices are common Chrysalis report 2011, MEDEC • In Canada 2011 • 5200 new ICDs, 2076 replacement ICDs • MAHI/U of A Hospital 2011/2012 • 210 new ICDs, 71 ICD generator changes • 261 new pacemakers, 73 pacemaker generator changes • HRDC MAHI/U of A • 1598 pacemaker patients, 1035 ICD patients • 5647 patient clinic visits Alberta Health Services

  3. ER Device Presentations • Post-operative complications • Symptoms due to the device working properly • Symptoms due to the device working improperly • Bystander for unrelated presentations • May impact care of primary presentation • May suspect problem with device

  4. Pacemakers: Bradycardia • Symptomatic bradycardia • Sinus node disease • AV disease – advanced second degree or third degree heart block • Asymptomatic high grade AV block • Not PACs with block, Type 1 second degree (inc. 2:1) • Syncope – bifascicular block • Chronotropic incompetence • No reversible cause (ie. Rx, vasovagal etc) Epstein AE, DiMarco JP et al. Circulation. 2008;117:2820-2840.

  5. The Pulse Generator: • Contains a battery that provides the energy for sending electrical impulses to the heart • Houses the circuitry that controls pacemaker operations Circuitry Battery Image www.medtronic.com

  6. Transvenous Leads Have Different “Fixation” Mechanisms • Passive fixation • The tines become lodged in the trabeculae(fibrous meshwork) of the heart • Active Fixation • The helix (or screw) extends into the endocardial tissue • Allows for lead positioning anywhere in the heart’s chamber Images www.medtronic.com

  7. Pacemaker Components Combine with Body Tissue to Form a Complete Circuit • Pulse generator: power source or battery • Leads or wires • Cathode (negative electrode) • Anode (positive electrode) • Body tissue Lead IPG Anode Cathode

  8. I II III IV V Programmable Antitachy Chamber Chamber Response Paced Sensed to Sensing Functions/Rate Function(s) Modulation NBG Code P: Simple programmable V: Ventricle V: Ventricle T: Triggered P: Pace M: Multi- programmable A: Atrium A: Atrium I: Inhibited S: Shock D: Dual (A+V) D: Dual (T+I) D: Dual (P+S) D: Dual (A+V) C: Communicating O: None O: None O: None O: None R: Rate modulating S: Single (A or V) S: Single (A or V) O: None

  9. Automatic Implantable Cardioverter Defibrillators • 24/7 cardiac monitoring and intervention • Treat VT/VF • Anti-tachycardia pacing (ATP) for VT • Cardioversion/Defibrillation for VT/VF • Treat bradyarrhythmias • Full pacing functions (single, dual) • Treat heart failure • Biventricular pacing

  10. www.hrsonline.org

  11. Secondary Prevention • Survivors of VT/VF arrest w/o reversible cause • ICDs associated with a mortality reduction of 27%1 • Patients with inducible VT on EPS • Syncope and ischemic heart disease • Non sustained VT and ischemic heart disease • Syncope and dilated cardiomyopathy • Unfortunately most patients don’t survive first episode 1AVID Investigators. N Engl J Med. 1997;337:1576-1583

  12. Consider Primary Prophylaxis AICD • EF less than or equal 35% • Ischemic cardiomyopathy (CCS Class 1) • more than 4 weeks post most recent MI • more than 3 months post revascularization • Dilated cardiomyopathy with Class II, III heart failure (CCS Class II a) • more than nine months after diagnosis • Benefit modest with ARR approximately 2%/year • Other high risk conditions eg. Long QT, ARVC etc.

  13. Discrimination: SVT vs VT • Heart Rate • A-V relationship • Onset • Stability • Morphology

  14. Morphology Analysis

  15. Re-Entry Murgatroyd, Krahn et al. Handbook of Cardiac Electrophysiology. 2002.

  16. Anti-Tachycardia Pacing • Pain free way of terminating VT • Burst pacing faster than the VT rate • More effective on slower VTs • Can accelerate VT Murgatroyd, Krahn et al. Handbook of Cardiac Electrophysiology. 2002.

  17. Cardiac Resychronization Therapy right atrium coronary sinus right ventricle Hare, NEJM 2002;346:1902-5

  18. Magnets and Devices • Pacemakers • Device paces at its predefined magnet rate • Asynchronous mode (DOO, VOO) • ICDs • Disables tachycardia detection • Does NOT affect pacing therapies

  19. Pacemaker Presentations • Failing to capture • Pacing spikes – no capture • Failing to sense • Pacing occurs where it shouldn’t – like on T wave • Failing to output • Oversensing – no pacing spikes because the device sees a signals it thinks are coming from heart beats – but they are not!

  20. Pacing - Tachyardia • Failure to mode switch – tracking of atrial fibrillation/flutter with rapid paced ventricular rate • Medications won’t control the rate • Pacemaker Mediated Tachycardia • Retrograde conduction to the atrium from a PVC starts a rapid pacing cycle via the pacemaker

  21. Hysteresis

  22. The DAVID Study – Adverse Effects of RV Pacing Objective To compare the efficacy of dual chamber pacing with back-up VVI pacing in patients with a standard ICD indication • 506 patients randomized to DDDR pacing at 70 bpmvs VVI back-up pacing at 40 bpm • No indication for bradycardia pacing • Maximal tolerated medical therapy JAMA. 2002;288(24):3115-3123

  23. Outcome: DAVID Trial The DAVID Trial Investigators, JAMA 2002;288:3115-3123.

  24. MVP Basic Operation DDD(R) Switch Ventricular support if lossof A-V conduction is persistent Image www.medtronic.com

  25. Complex Pacing Algorithms • Minimize RV Pacing • Mode switching algorithms • AV delay extension algorithms • Prevention of atrial fibrillation • Atrial overdrive / PAC suppression • Rate smoothing in persistent atrial fibrillation • Pacing in ventricle may result in a slower average ventricular rate

  26. Patient Shocks • Normal function of the AICD • Patient feels well post shock(s) • Leave message with AICD Clinic • Scheduled assessment within few days • Patient feels unwell post shock(s) • Go to nearest ER • Patient with an device/lead under a manufacturer’s advisory may require urgent assessment also

  27. Inappropriate Shocks • Shocks received for reasons other than VT/VF • Causes include: • Sinus tachycardia • Atrial fibrillation with a rapid ventricular response • Other supraventricular tachyarrhythmias • Lead Fracture • External noise

  28. Complications Lead dislodgement 2.3% Early ICD system infection 1.9% Pneumothorax 0.6% Device malfunction 0.5% Serious bleeding 0.4% Venous thrombosis 0.2% Cardiac perforation 0.1% CCS/CHRS Position Paper on Implantable Cardioverter Defibrillator (ICD) Use in Canada

  29. Post-op Site Check

  30. Hematoma

  31. Post AICD Implant – 12 months

  32. ` Parsonnet V, Trivedi A. Circulation. 2000;102:1192.

  33. Lead Infection • Clinical symptoms suggestive of systemic infection and positive blood cultures warrant further evaluation with TEE • “Strands” and clot on leads can be a normal finding • Sometimes appearance can be highly suggestive of infection

  34. Leads Attached to Veins by Fibrotic Tissue

  35. Preventing Infections • ECG Electrode on device site can cause erosion • Starting heparin or low molecular weight heparin will cause a large hematoma • Central lines provide a route for sepsis and lead infection • Sepsis from any source can settle on the device leads

  36. Peri-Operative Device Management Device type and indication Pacemaker dependence Surgery location Accessibility to device site during procedure Canadian Cardiovascular Society/Canadian Anesthesiologists/Canadian Heart Rhythm SocietyJoint Position Statement on the Perioperative Management of Patients with Implanted Pacemakers, Defibrillators and Neurostimulating Devices. CJC 28(2012) 141-151.

  37. Reason for a device check • Patient symptoms • Shocks • Syncope/Significant presyncope • Palpitations • Also consider: SOBOE: chronotropic incompetence, loss of BiV pacing • Documented device failure (on ECG) • Patient lost to device follow-up

  38. Remember Settings/notes available from Device Clinic Presence of patient in hospital is not an indication to check the device We’re here to help

  39. Conclusion ≠

  40. Heart Rhythm Device Clinic • Pacemaker Clinic – Nurse run, physician supervised • 4 weeks, 3 months, 6 months, 12 months • Assess patient symptoms • Lead performance • Battery Status • Programming changes • ICD Clinics – EP Physician attended • Anti-arrhythmic medications checked • Episodes recorded by the device reviewed

  41. CRT requires wide complex ECG and Class II+ CHF

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