HEART OF THE MATTER: cardiac issues in safe endoscopy & sedation
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1 HEART OF THE MATTER: cardiac issues in safe endoscopy & sedation YUVAL KONSTANTINO M.D. CARDIOLOGY DEPARTMENT, ELECTROPHYSIOLOGY UNIT, SOROKA MEDICAL CENTER, BEN-GURION UNIVERSITY
2 OUTLINE Anticoagulation therapy: Vitamin K antagonists NOACs Antiplatelets therapy Aspirin Clopidogrel, Prasugrel, Ticagrelor Cardiac implantable devices Pacemakers Defibrillators
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6 How should we manage the anticoagulation therapy before endoscopic procedures?
7 CHA2DS2 VASC score in non-valvular Atrial Fibrillation
8 Yao x et al. Effect of Adherence to Oral Anticoagulants on Risk of Stroke and Major Bleeding Among Patients With AF. J Am Heart Assoc. 2016
9 Yao x et al. Effect of Adherence to Oral Anticoagulants on Risk of Stroke and Major Bleeding Among Patients With AF. J Am Heart Assoc. 2016
10 Yao x et al. Effect of Adherence to Oral Anticoagulants on Risk of Stroke and Major Bleeding Among Patients With AF. J Am Heart Assoc. 2016
11 Perioperative bridging of anticoagulation in patients with atrial fibrillation Douketis JD et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med. 2015
12 Perioperative bridging of anticoagulation in patients with atrial fibrillation Douketis JD et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med. 2015
13 Perioperative bridging of anticoagulation in patients with atrial fibrillation In patients with atrial fibrillation who require perioperative interruption of warfarin treatment for an elective procedure, a strategy of discontinuing warfarin treatment without the use of bridging anticoagulation was noninferior to the use of bridging anticoagulation Bridging conferred a risk of major bleeding that was nearly triple the risk associated with no bridging Douketis JD et al. Perioperative Bridging Anticoagulation in Patients with Atrial Fibrillation. N Engl J Med ;373(9):823-33
14 Bridging should be considered in the following cases: Mechanical valves Rheumatic heart disease: Mitral stenosis History of TIA/CVA High CHA2DS2 VASC score
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17 No Bridging Bridging Procedure on Anticoagulation/ NOACS No Bridging
18 OUTLINE 2 3 Antiplatelets therapy Aspirin Clopidogrel, Prasugrel, Ticagrelor Cardiac implantable devices Pacemakers Defibrillators
19 78 y.o Male Anterior wall MI Primary PCI with stent to mid LAD Discharged with dual anti-platelets therapy including Prasugrel and Aspirin What is the optimal duration of DAPT therapy after PCI?
20 2017 ESC focused update on dual antiplatelet therapy. Eur Heart J ;39:
21 What is the optimal duration of DAPT therapy after PCI? One year after PCI for ACS and 6 months after PCI for stable CAD, regardless of the stent type
22 Back to our patient One month later, patient presents with Iron deficiency Anemia Scheduled for endoscopy How should we manage his anti-thrombotic therapy?
23
24 STABLE ACS 2017 ESC focused update on dual antiplatelet therapy. Eur Heart J ;39:
25 2017 ESC guidelines 2017 ESC focused update on dual antiplatelet therapy. Eur Heart J ;39:
26 APAGE & APSDE guidelines The Task Force recommends discussion with the cardiologist before discontinuation of antiplatelet therapy, particularly in patients with acute coronary syndrome within 6 months As a general principle, we do not recommend withholding both antiplatelet agents simultaneously because the median time to coronary stent thrombosis Management of patients on antithrombotic agents undergoing emergency and elective endoscopy: joint Asian Pacific Association of Gastroenterology (APAGE) and Asian Pacific Society for Digestive Endoscopy (APSDE) practice guidelines.
27 2017 ESC focused update on dual antiplatelet therapy. Eur Heart J ;39:
28 OUTLINE 3 Cardiac implantable devices Pacemakers Defibrillators
29 Healey JS et Al. Canadian Cardiovascular Society/Canadian Anesthesiologists. Can J Cardiol. 2012; 28:
30
31 Healey JS et Al. Canadian Cardiovascular Society/Canadian Anesthesiologists. Can J Cardiol. 2012; 28:
32 The procedure team must advise the CIED team about the nature of the planned procedure The CIED team will provide guidance in the form of a prescription to the procedure team for the management of the CIED The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors. Heart Rhythm. 2011; 8:e1-18.
33 By far, the most frequent CIED interaction with EMI is oversensing, which results in inappropriate inhibition of pacing output For a patient with a robust underlying rhythm, pacing inhibition may be inconsequential; while a pacemaker dependent patient may experience a hemodynamically unstable underlying rhythm with prolonged pacing inhibition. The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors. Heart Rhythm. 2011; 8:e1-18.
34
35 Inhibition of pacing by electromagnetic interference (EMI)
36 A magnet placed over a pacemaker will always render the pacing mode asynchronous by interruption of the sensing function A magnet is an appropriate option for any patient who is pacemaker dependent. The magnet should be secured over the device Reprogramming of the device to asynchronous mode is optional The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors. Heart Rhythm. 2011; 8:e1-18.
37 NOISE Inappropriate VF detection ICD shock Defibrillators: noise = inappropriate shocks
38 To make things more complicated:
39 Monitoring All patients with a CIED undergoing a procedure with a risk of EMI interaction require cardiac rhythm monitoring External defibrillation equipment is required in the OR and immediately available for all patients with pacemakers or ICDs having surgical and sedation procedures where EMI may occur Some patients may need to have pads placed prophylactically during surgery (e.g., high risk patients and patients in whom pad placement will be difficult due to surgical site) The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors. Heart Rhythm. 2011; 8:e1-18.
40 The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers. Heart Rhythm. 2011; 8:e1-18.
41 THANK YOU
42
43 Mechanical prosthetic valve: The European approach
44 Mechanical prosthetic valve: The American approach BRIDGE STUDY
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46 Experience has demonstrated, and literature suggests, that in a CIED implanted in the usual upper chest position, oversensing problems are unlikely for operative procedures where the application of electrosurgery will be inferior to the umbilicus and the return electrode is placed on the lower body (thigh or gluteal area) The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors. Heart Rhythm. 2011; 8:e1-18.
47 A magnet placed over an ICD generator will not render pacemaker function in an ICD asynchronous Inactivation of ICD detection is recommended for all procedures using monopolar electrosurgery or RF ablation above the umbilicus. In pacemaker patients, no reprogramming is usually needed if the electrosurgery is applied below the level of the umbilicus. The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors. Heart Rhythm. 2011; 8:e1-18.
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