ICD Diagnostics: Making the most of it

Transcription

1 ICD Basics and Beyond ICD Diagnostics: Making the most of it Dulce Obias-Manno RN, BSN, MHSA, FHRS, CCDS, CEPS Cardiac Arrhythmia Center, Device Clinic Washington Hospital Center, Washington DC

2 Objectives The participant will recognize the value of ficddi diagnostic data The participant will learn how to use diagnostic data efficiently at follow-up

3 ICDs through the years PCD 7216 GEM DR Jewel PCD 7217 GEM III AT Micro Jewel II Maximo EnTrust GEM II DR Marquis Intrinsic Virtuoso Courtesy of Medtronic Inc

4 How did we get here? Shock box Tiered therapy Biphasic waveform Transvenous leads, active can, pectoral implant,micro processor #shocks charge time stored intervals, markers, EGMs Lead data, increased memory, diagnostics

5 Average ICD Implant Time D uration (h hr) Epicardial Mono Transvenous Biphasic Transvenous Biphasic Pectoral Active Can Courtesy of Medtronic Inc

6 How did we get here? AVID, CASH,SIDSSIDS COMPANION MIRACLE ICD MADIT, MUSTT MADIT II SCD-HeFT Shock box Tiered therapy Biphasic waveform Transvenous leads, active can, pectoral implant,micro processor Dual chamber pacing, Rateresponsive pacing, AT therapies Minimize RV pacing, CRT- D, capture management #shocks charge time stored intervals, markers, EGMs Lead data, increased memory, diagnostics Rate histograms, AT/AF events, lead trends, SVT discriminators, i i patient alert Functional status, physiologic measures, trends, daily testing

7 Annual ICD Implants (approximate) 80,000 (55,400) 60,000 (37,100) 40,000 (21,000) 20,000 (350) (1,600) (4,200) (7,800) (17,200) United States Courtesy of Medtronic Inc

8 How did we get here? AVID, CASH,SIDSSIDS COMPANION MIRACLE ICD MADIT, MUSTT MADIT II SCD-HeFT Shock box Tiered therapy Biphasic waveform Transvenous leads, active can, pectoral implant,micro processor Dual chamber pacing, Rateresponsive pacing, AT therapies Minimize RV pacing, CRT- D, capture management Electronic repositioning, Remote monitoring, wireless telemetry, autooptimization #shocks charge time stored intervals, markers, EGMs Lead data, increased memory, diagnostics Rate histograms, AT/AF events, lead trends, SVT discriminators, i i patient alert Functional status, physiologic measures, trends, daily testing Patient alerts, Auto clinic notification, multiple EGM views, expanded diagnostics

9 Current Status Current generation ICDs are equipped with more diagnostic data reflecting ect on Clinical status EGMs: Presenting and stored Ventricular event logs Atrial arrhythmia burden Percent paced, average heart rate, rate histograms Functional status: activity level, autonomic measures, HR variability, respiratory rate trends, BP and weight monitoring Device functionality Arrhythmia discrimination sequence used Pacing appropriate or inappropriate for patient Utility of monitored, untreated events Evaluation of programmed parameters Remote device integrity check AV delay optimization Hardware integrity Battery real time measurements/longevity Lead real time measurements Lead trends Intrinsic amplitude trends Capture threshold trends Event EGMs, NSVT frequency Short R-R interval frequency occurrence

10 Increased diagnostic data: Balancing the good and the bad Supplementary data source Increased battery drain Time consuming Overwhelming

11 Increased diagnostic data: Balancing the good and the bad E f f i c i e n c y Increased battery drain Supplementary data source Improved battery technology Time consuming Overwhelming Optimize i Customize

12 Tips for optimizing diagnostic data Start with the fundamentals Summary of events and parameters, presenting EGM, measured values, capture and sensing data, battery status

13 Enhance clinical diagnostics with patient reported symptoms arrhythmia hth discrimination, i i arrhythmia burden, lead and event trends Summary of events and parameters, presenting EGM, measured values, capture and sensing data, battery status

14 % pacing, auto measurem ents, historical data etc arrhythmia hth discrimination, i i arrhythmia burden, lead and event trends Summary of events and parameters, presenting EGM, measured values, capture and sensing data, battery status

15 Case Study #1: Understanding the fundamentals 29 year old female with Hx of post-partum CHF, HCM, family history of SD. A dual chamber ICD was implanted for primary prevention on 25 June On Dec 3,2008 the patient reported feeling tired and sent an unscheduled interrogation. Remote monitoring electrograms are shown. HR: 92 bpm? accelerated Junctional rhythm?avnrt

16 Case Study #1 Device Status (Implanted: 25-Jun-2007) Measured on: Battery Voltage (RRT=2.62 V) 3.14 V 03-Dec-2008 Last Full Charge 9.5 sec 25-Aug-2008 Atrial(4076) RV(6949) SVC Pacing Impedance ohms 03-Dec-2008 Defibrillation Impedance RV=49 ohms 03-Dec-2008 SVC=65 ohms 03-Dec-2008 Programmed Amplitude/Pulse Width 2 V / 0.4 ms 5V/0.8ms Measured P/ R Wave 3.1 mv 3.3 mv 03-Dec-2008 Programmed Sensitivity 0.9 mv 0.3 mv Parameter Summary Mode DDD Lower Rate 40 bpm Paced AV 120 ms Mode Switch 171 bpm Upper Track 150 bpm Sensed AV 100 ms Upper Sensor 130 bpm Detection Rates Therapies AT/AF Monitor >171 bpm All Rx Off VF On >207 bpm 35J x 6

17 Case study#1: Findings Therapy Summary VT/VF AT/AF Pace-Terminated Episodes 0 0 Shock-Terminated Episodes 0 0 Total Shocks 0 0 Aborted Charges 0 0 Pacing (% of Time Since 21-Nov-2008) AS-VS 100.0% AS-VP < 0.1% AP-VS 0.0% AP-VP 0.0% 0% MVP Off R Wave Amplitude At Implant 16.3 mv Highest 18.3 mv Last 4.0 mv Lowest 1.7 mv The patient was seen in clinic on 12/4/08. RV capture was absent. The patient reports she was fishing and pulling heavy nets weeks before the ICD monitoring. Fluoroscopy revealed RV lead dislodgement to low right atrium. She underwent lead extraction and implantation of a new RV lead.

18 Tips for optimizing diagnostic data Verify accuracy of data source Brady and CRT Counters Since Last Remote Follow-up: 20 Nov 2008 Percent Paced Atrial 0 % Right Ventricular 100 % Left Ventricular 100 % ATR Mode Switch Number of Mode Switches 179 Minimum Duration 00:00 mm:ss* Maximum Duration 00:35 mm:ss* *Value based on the most recent 184 ATR episodes collected by LATITUDE.

19 Tips for optimizing diagnostic data View data from horizontal and vertical time lines

20 Tips for optimizing diagnostic data Do not obsess over irrelevant details during routine follow-up One cannot manage too many affairs: like pumpkins in the water, one pops up while you try to hold down the other Chinese Proverb

21 Make the most of it! Organize and archive patient data in electronic data storage Accessible, confidential Adjust parameters and automatic alerts parameters tailored to patient s needs When troubleshooting, use all data available, do manual lead tests, obtain patient history then connect the dots

22 One final point When you don t understand, seek help from the experts (technical support, Electrophysiologist, peers ) Experience is what you get when you didn t get what you wanted Randy Pausch in The Last Lecture