Your Patient has a CIED (Cardiac Implantable - PowerPoint Presentation

Slide1

Your Patient has a CIED (Cardiac Implantable Electronic Device): Now What?

Laurie

Racenet

, FNP, MSN, CCDS, CEPS, FHRS

Alaska Heart and Vascular

I

nstituteSlide2

Types of DevicesPacemakers

Single

Dual

BiV

(CRT)

Leadless

ICDs

Single

Dual

BiV

(CRT)

S-ICD (sub Q implant)

Loop RecordersSlide3

What Functions do the devices perform?PacemakersPace the heart to prevent bradycardia

Can increase heart rate with activity

Records diagnostic information about the patient

Some devices can deliver anti-tachycardia pacing for atrial arrhythmias onlySlide4

What Functions do the devices perform?ICDsPace the heart to prevent bradycardiaCan increase heart rate with activity

Records diagnostic information about the patient

Deliver

anti-tachycardia pacing for

atrial and ventricular arrhythmias

Deliver shock for ventricular arrhythmiasSlide5

What Functions do the devices perform?Loop recordersRecord abnormal rhythms automatically

Patients can activate the device to record on demandSlide6

Basic Pacemaker FunctionsPace the heart at a programmed rate

Sense the hearts intrinsic rhythm and inhibit pacing, so the pacemaker does not compete with the intrinsic rhythm

Sense an intrinsic signal and trigger a response.

Modes

AAI

VVI

DDD

AOO

VOO

DOOSlide7

Basic ICD FunctionsSame as pacemaker for the pacing portion of the deviceDetect VT and VF

Deliver anti-tachycardia pacing (ATP)

Deliver a shockSlide8

What do Magnets do to devices?Pacemakers

Temporarily place the device in a non-sensing mode

The device will not respond to a sensed event and will continue to pace at a set rate

The device will automatically return to previous programming when the magnet is removed

Rate is dependent on each different manufacturer and can sometime vary based on the battery life of the device

ICD

Suspends the detections and therapies in the defibrillator portion of the device only. Pacemaker functions are left unchanged.

Removing the magnet will automatically unsuspend the detection and therapy portion of the device

Loop recorders

No effectSlide9

Is there an advantage to using a magnet during a procedure?2011 HRS/ASA Expert Consensus Statement on the Perioperative Management of Patients with Implantable Defibrillators, Pacemakers, and Arrhythmia Monitors: Facilities and Patient

Management

http://www.hrsonline.org/Policy-Payment/Clinical-Guidelines-Documents/Expert-Consensus-Statement-on-the-Perioperative-Management-of-Patients-with-Implantable-Defibrillators-Pacemakers-and-Arrhythmia-Monitors/2011-Expert-Consensus-Statement-on-the-Perioperative-Management-of-Patients-with-Implantable-Defibrillators-Pacemakers-and-Arrhythmia-MonitorsSlide10

Is there an advantage to using a magnet during a procedure?ICD-ON Registry for Perioperative Management of CIEDs: Most Require No Change JANET GIFFORD, M.S.N., A.C.N.P.,* KAREN LARIMER, PH.D., A.C.N.P., F.A.H.A.,† CELIA THOMAS, M.S.N., C.N.S.,* and PATRICIA MAY, M.S., A.C.N.P

.‡ - PACE: Feb 2017

“Our

findings support that perioperative CIED management should be individualized based on surgical location. If surgical location is within 6 inches of the CIED, reprogram ICD therapies off and if pacemaker dependent change to asynchronous pacing. For ICD patients with surgical location above the iliac crest yet greater than 6 inches from the ICD, use a magnet. And finally, no change for any pacemaker greater than 6 inches from the surgical site, and no change for any ICD with surgeries that occur below the iliac crest

.”Slide11

Is there an advantage to using a magnet during a procedure?Often the best approach is to have the patient’s EP decide whether to reprogram or use magnet. As in all things, patient care is enhanced with cooperation between disciplines.

Reprogramming for surgery means the device MUST be reprogrammed to its normal function after the surgery is complete.

If a magnet is used, the device will automatically return to normal function and no reprogramming is needed

Often the decision to reprogram will be based on several issues:

Is the patient dependent

Does the patient need to maintain a specific heart rate during the procedure

How close is the surgery site to the device

What equipment will be used during surgery

How to contact EP:

561-3211 – ask to speak to the physician’s nurseSlide12

What if a Device Malfunctions during the procedure?Remember BLS and ALS – treat the patient, not the device

REMOVE THE MAGNET: If an ICD patient has a magnet on and has VF/VT, take the magnet off immediately. The device will shock more quickly than you can get the external defibrillator set up.

How to page the EP on call: 222:EPMD (3763)

How

to page the on call rep to reprogram a device or if you have an emergency during a procedure

Medtronic:

1-800-MED-TRON (633-8766)

Abbot (St. Jude Medical): 1-800-722-3423

Boston Scientific

Corp:1-800-CAR-DIAC (227-3422)

Biotronik

: 1-822-284-6689Slide13

Monitoring Considerations during procedure1. Keep an eye on the BP and O2 Sat as well as the heart monitor

2. Don’t be too worried if you don’t see a pacer spike - they are sometimes very small on the monitor

3. If you do have to defibrillate, try not to place electrodes directly over the device, and have the device interrogated by a rep as soon as feasible after the crisis has passed.

4. If there is concern about the device, do not hesitate to call EPMD on call, or Rep on call

5

. If you have specific, non-urgent questions, you can call the device clinic at 561-3211.

6. If the device was reprogrammed prior to the procedure, be sure that a rep has been in and reprogrammed to device to pre-procedure settings before discharge.Slide14

A couple of special issuesLoop Recorders:

No action is needed – no pacing or therapy functions on these devices – recording only

S-ICD

No pacing function with this device

No leads in the heart

Magnet is almost always the best choice for this device during surgery

Boston Scientific has the only S-ICD on the market

Leadless Pacemaker

Magnet cannot be used to place this device in non-sensing mode and the device rep will need to reprogram it before and after the procedure

Currently the Medtronic

Micra

device is the only one on the marketSlide15

Leadless systemSlide16

S-ICDSlide17

Implantable Loop Recorder