12 th International Winter Arrhythmia School Collingwood, Ontario February 7, Dr. Derek Yung. MD, FRCPC
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1 12 th International Winter Arrhythmia School Collingwood, Ontario February 7, 2015 Dr. Derek Yung. MD, FRCPC
2 Presenter: Dr. Derek Yung Relationships with industry: Educational material provided by Biotronik, Guidant, Medtronic, St. Jude Medical, Sorin Grant / Research Support: Not applicable Commercial Support: No honorarium Mitigation of Bias: Review of peer- reviewed literature and industry provided manuscripts to support the content of this presentation.
3 ! Background! Magnet Application! Why and How?! Magnet Response! Pacemakers! Implantable Cardioverter Defibrillators! Summary
4 "If you suddenly get the urge to kick it, press the call button immediately"
5
6 ! 3 Million North Americans living with CIEDs! 250,000 devices implanted each year! Increasing dramatically due to the aging population! Profound impact on morbidity and mortality
7 With Great Power Comes Great Responsibility
8 ! Background! Magnet Application! Why and How?! Magnet Response! Pacemakers! Implantable Cardioverter Defibrillators! Summary
9 Jacob et al., Europace 2011, 13:
10 A. Assessment of battery status in a pacemaker B. Inappropriate ICD shocks due to a lead fracture. C. Inappropriate ICD shocks due to rapid atrial fibrillation D. Dependent ICD patient requiring thoracic electrocautery E. Termination of pacemaker mediated tachycardia
11 MITIGATES CONSEQUENCES OF OVERSENSING / NOISE PPM + = ASYNCHRONOUS PACING ICD + = TACHY RX OFF
12 EMI is anticipated 1. PERIOPERATIVE / ELECTROCAUTERY 2. Extracorporeal shock- wave lithotripsy 3. Therapeutic radiation 4. RF ablation 5. TENS units 6. Electroconvulsive therapy Device Troubleshooting 1. Battery status 2. Capture threshold 3. Device identification Therapeutic 1. PMT intervention 2. Inappropriate therapies (ie. Lead fracture, cross- talk / far- field sensing, non life- threatening arrhythmias etc) 3. Palliation
13 ! Inappropriate CIED sensing of EMI! No effect! Inhibition! Tracking (rapid pacing)! ICD therapy (ATP or shocks)! Physical damage or reprogramming Schulman et al., Anesth Analg 2013;117, 422 7
14 Crossley et al., Heart Rhythm 2011, 7: Healey et al., CJC 2012, 28:
15 Healey et al, CJC 2012, 28:
16 Greater Probablity for EMI: Jacob et al., Europace 2011, 13: ! Anatomical considerations (above > below the umbillicus)! < 15 cm from the CIED or leads! Monopolar > Bipolar cautery! Long (> 5 seconds) or frequent (< 5 seconds in between bursts) of cautery! Unipolar leads or bipolar leads programmed to unipolar
17 ! NOT accessible and visible! Poor positioning - Prone or lateral! CIED is in the surgical field! Magnet response to the CIED is not known! Low battery! Pacer dependent ICD patients
18 MINIMAL / NO ELECTROCAUTERY SIGNIFICANT / UNAVOIDABLE ELECTROCAUTERY DEPENDENT NON-DEPENDENT Pacemaker NO changes to programming Consider MAGNET (if not reprogram to asynchronous pacing)* Synchronous mode (at physiologically acceptable rate) Brady Function of ICD NO changes to programming Consider REPROGRAMMING to asynchronous pacing* Synchronous mode (at physiologically acceptable rate) Tachy Function of ICD NO changes to programming Use MAGNET (if not reprogram to disable tachy therapies) *Biotronik has a Noise Mode and does NOT require any action for dependent patients.
19 A. No treatment needed B. Synchronous pacing, but reprogram the lower rate and turn off rate response C. Magnet on device D. Reprogram to asynchronous pacing
20 ! Background! Magnet Application! Why and How?! Magnet Response! Pacemakers! Implantable Cardioverter Defibrillators! Summary
21 A. B. C. D. E. IT DEPENDS
22 Sorin Guidant / Biotronik Jacob et al., Europace 2011, 13:
23 ! Background! Magnet Application! Why and How?! Magnet Response! Pacemakers! Implantable Cardioverter Defibrillators! Summary
24 PPM + = ASYNCHRONOUS PACING ICD + = TACHY RX OFF WHAT ARE THE UNIQUE CONSIDERATIONS?
25 A. A DDD pacemaker will pace DOO B. A dual chamber pacemaker programmed in VVI mode will pace VOO C. A device programmed in AAI <==> DDD mode will pace DOO D. Synchronous pacing E. All of the above
26
27 Capture / Rate test upon magnet removal. Europace 2011, 13:
28 ! Background! Magnet Application! Why and How?! Magnet Response! Pacemakers! Implantable Cardioverter Defibrillators! Summary
29 A. A sustained alert tone is heard B. An intermittent beep is heard C. Asynchronous pacing D. There is no way to know E. It depends (all of the above are possible)
30 MAGNET = TACHY Rx SUSPENDED DEVICE RESPONSE Boston Scientific * Tachy Rx ON but Supressed Tachy Rx OFF Toggle Mode Medtronic * St. Jude All Clear Tone Low Urgency High Urgency No Audio Biotronik No Audio (must reapply after 8 hours) Sorin No Audio. Pacing at bpm (no change in pacing mode) * If NO tone heard = magnet position, battery depleted, wrong manufacturer Jacob et al., Europace 2011, 13:
31 1. APPLY Magnet for 30 Seconds 2. Remove for 10 seconds (2 ft from device) 3. REAPPLY Magnet to test BOSTON SCIENTIFIC /GUIDANT MODELS TOGGLE MODE Toggle mode available PRIZM 1 ( , ), PRIZM 2 ( ) VITALITY 1 (T125, T127, T135) NO Toggle mode VITALITY 2 (T165, T167, T175, T177, T180, A135, A155) CONFIENT (E030), TELIGEN (E110) COGNIS (N118, N119), LIVIAN (H220, H225, H227, H229) INCEPTA (E ), PUNCTUA (E ) ENERGEN (E ) Software patch to inactivate Toggle mode CONTAK RENEWAL 1 H135 CONTAK RENEWAL 3/4 H170, H175, H177, H179 CONTAK RENEWAL 3RF H210, H215, H217, H219
32 A. The patient is obese B. Store EGM mode was turned ON 3 months ago C. Magnet is not in the correct position D. Magnet mode is OFF E. Low battery status
33 ! St. Jude (right)! NORMAL / IGNORE! Boston / Guidant (below)! ON / STORE EGM / OFF
34 ! Boston / Guidant! Store EGM!! 2 min beore, 1 min after Resets to inhibit mode after one stored EGM OR after 60 days! Electrocautery mode! Magnet has no effect
35 1. Improper magnet position! ICDs - Boston / Medtronic (Alert), Sorin (96-80 bpm)! Submuscular implants and obese patients 2. Magnet swtich is OFF! ICD - Boston / SJM! PPM BOS, SJM, Biot, Sorin 3. Low battery voltage! Unpredictable at EOL 4. Magnet Reapplication! Biotronik devices (after 8 hours)
36 ! MRI Conditional devices "MRI mode"! Medtronic SureScan overrides magnet mode! Biotronik Pro MRI mode overrides magnet mode! Sorin (Kora 100) Programmable during monitoring window! S- ICD! Alert:! Magnet Inhibits Tachy Rx
37 ! Magnet application on CIEDs remains a useful diagnostic and therapeutic tool! It can be used to prevent interaction with electrocautery in selected patients! The conventional response is asynchronous pacing for pacemakers, and inhibition of tachytherapy for ICDs! Unexpected effects and adverse consequences can result from improper magnet use or an incomplete understanding of manufacturer specific magnet settings
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EnTrust D154VRC Single Chamber ICD 35J delivered 8 seconds BOL, 11.8 seconds ERI 10.7 years**** 35cc, 68g Programmable Active Can
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