Pediatric pacemakers & ICDs:

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1 Pediatric pacemakers & ICDs: perioperative management Manchula Navaratnam Clinical Assistant Professor LPCH, Stanford SPA 2016

2 Conflict of interest: none

3 Objectives Indications in pediatrics Components Programming modes Perioperative care plan Trouble shooting

4 Some definitions Pacemaker: Pace heart ± sense intrinsic beat ICD: Implantable Cardioverter Defibrillator Pacemaker + treat life threatening arrhythmias. CIED: Cardiovascular Implantable Electronic Device (Pacemakers or ICDs)

5 History

6 Indications: pediatric CIEDs 2008 AHA updated guidelines: Age appropriate heart rate criteria Specific pediatric issues Mainly consensus based evidence (Level C) Class 1 to Class III recommendations

7 Indications: pediatric pacemakers Sinus node dysfn AV node block Congenital heart disease (CHD) Symptomatic bradycardia (Class 1) Congenital(Class I) Acquired (Class I) 7-10 days post cardiac surgery

8 Indications: pediatric ICDs Primary prevention for increased risk of SCD (Class II) Sustained ventricular arrhythmias (Class I) Secondary prevention of Sudden Cardiac Death (SCD) (Class I)

9 Cardiac resynchronization therapy (CRT) Chronic RV pacing secondary dilated cardiomyopathy & impaired LV function CRT improves mechanical efficacy in hearts with ventricular dysynchrony Children most likely to benefit have LBB morphology on ECG Right atrial lead Left ventricular lead (coronary sinus) Right ventricular lead

10 CIED system: 4 components Implantable pulse generator (IPG) Lead Body tissue Programmer

11 Epicardial vs. Transvenous Patient EPICARDIAL < 15kg Limited access to atrium/ ventricle. Intracardiac shunts TRANSVENOUS Everybody else! Technique Thoracotomy or mini sternotomy (CT surgeon) Seldinger technique (EP physician) Generator site Abdomen Chest Leads Thresholds More prone to fracture; Higher lead failure Higher pacing thresholds: Early battery depletion Lower lead fractures risk of dislodgement, venous occlusion, endocarditis Lower pacing thresholds: Longer battery life

12 Transvenous vs. Epicardial IPG RA lead RV lead Defibrillator coil (thick) IPG

13 Unipolar vs. Bipolar + Anode + - Cathode Anode + - Cathode Larger inter-electrode distance Smaller inter-electrode distance Co-axial design

14 Lead fractures

15 Growth spurts & leads

16 NAPSE/BPEG (NBG) code 1 st Pacemaker 1st Letter Chamber(s) Paced 2nd Letter Chamber(s) Sensed 3rd Letter Response to Sensing V O O Then V V I Early dual chamber V A T Now D D D

17 NBG 5 letter code Advance functions Rate modulation: Increase HR to meet metabolic demands e.g. DDDR

18 Single chamber pacing Mode: AAI

19 Single chamber pacing: Mode: VVI

20 Single chamber pacing Mode: VOO (asynchronous pacing)

21 Dual chamber pacing Mode: DDD- AV sequential pacing

22 Dual chamber pacing Mode: DDD- atrial synchronous pacing

23 DDD pro/con Maintains AV synchrony: end diastolic volume & cardiac output Too frequent ventricular pacing in DDD mode adverse LV remodeling and decreased function New algorithms to avoid ventricular pacing Managed ventricular pacing(mvp) AAI(R) DDD(R)

24 ICD Code & programming ICDs measure R-R interval Enough short R-R intervals detected antitachycardia pacing or shock Most devices VVE-DDDR

25 Formulating a periop care plan 2011 ASA/HRS practice advisory Thorough preop assessment Minimizing & managing electromagnetic interference(emi) Bipolar leads & improved technology reduce EMI but risks still exist

26 EMI & CIEDs: the risks. Inappropriate triggering or inhibition of paced output NO EMI EMI

27 EMI & CIEDs: the risks Inappropriate shock from ICDS ( myocardial injury (Moss et al NEJM 2012))) Figure from Rozner et al A&A 2015

28 EMI & CIEDs: the risks.. Current induced in leads electrical discharge to myocardium arrhythmias or burns changes in threshold & loss of capture

29 EMI & CIEDs: the risks.. Reversion to an asynchronous (noise suppression mode)

30 EMI (radiofrequency waves Hz) Sources Electrocautery monopolar>>>>bipolar Therapeutic radiation RF ablation MRI Lithotripsy External defibrillation Nerve stimulator Fasiculations Large tidal volumes Reducing EMI Bipolar diathermy If monopolar use lowest energy & short bursts Grounding pad away from device & current flow should not intersect device Good skin contact with grounding pad

31 The magnet Pacemaker asynchronous mode: AOO, DOO or VOO at preset magnet rate ICDs suspend antitachycardia function but does NOT convert to asynchronous pacing

32 The magnet: pitfalls Preset magnet rate Varies with manufacturer & battery life May not be sufficient for pediatric patient Asynch mode not always desirable Some ICDs have a magnet off switch

33 History and exam Diagnostics Consultation Preop evaluation: a practical approach Indication for CIED? Underlying rhythm CXR: Leads number & integrity, IPG code 12 lead ECG Underlying rhythm, rate & pacer dependency Co-existing CV pathology Manufacturer card Generator location Most recent interrogation report: Device type & parameters, pacer dependency, battery status, thresholds, lead impedance Sources of EMI Need for asynch mode? Change back up parameters? Magnet response

34 Intraop plan: pacemaker Is EMI likely? NO Proceed with surgery YES Pacer dependent? NO Surgery <15cm from CIED NO Have magnet available YES Convert to asynchronous mode (magnet or reprogram) Rate > patient s intrinsic rate YES Determine if asynch mode is advantageous

35 Intraop plan: ICD Is EMI likely? NO Proceed with surgery YES YES Deactivate ICD (magnet or reprogram) Pacer dependent? NO Reprogram to asynchronous mode Magnet will not convert to asynch Surgery <15cm from CIED? YES NO Discuss need for asynch mode Magnet will not convert to asynch Proceed with surgery

36 Intraop considerations CIEDs Monitor peripheral pulse and rhythm Reprogram before drapes and prepping Alternative methods of pacing /defibrillation Maintain electrolyte and metabolic normality Anesthesia induced changes(rate, rhythm, ischemia) may affect patient-cied interaction

37 Post op care Reset devices that were reprogrammed Restore anti-tachycardia therapies Interrogation of devices: check pacing & sensing thresholds after major surgery

38 Loss of capture Loss of output Trouble shooting Oversensing Undersensing

39 Loss of capture Threshold rise (inflammation, edema, myocardial disease, electrolytes, ph, hypoxia, drugs, infection, lead maturation) Fractured/dislodged lead Battery depletion Faulty cable connections

40 Loss of output (failure to pace) Oversensing Battery depletion Fractured/dislodged lead Faulty cable connection Circuit failure

41 Undersensing Inappropriate sensitivity setting Change in native signal Lead fracture/dislodgement Battery depletion Insulation break

42 Oversensing Exposure to interference(emi) Poor connection Lead fracture Insulation break

43 To summarize Comprehensive pre-op assessment 24 hour manufacturer help line 3 questions when planning intraop care: Is EMI likely? Is patient pacer dependent? Is surgery < 15 cm CIED?

44 Thank you!

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