Need to Know: Implantable Devices. Carolyn Brown RN, MN, CCRN Education Coordinator Emory Healthcare Atlanta, Georgia
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1 Need to Know: Implantable Devices Carolyn Brown RN, MN, CCRN Education Coordinator Emory Healthcare Atlanta, Georgia
2 Disclosure Statement I have no relationships to disclose.
3 Objectives Discuss the most current method of device implantation Describe indications for device therapy in the cardiac patient Manage troubleshooting in patients with an ICD or pacemaker. Address patient education and precautions.
4 Device Therapy Pacemaker ICD Pacemaker/ICD Cardiac Resynchronization Therapy (biventricular pacemaker) Biventricular Pacemaker/ICD
5
6 Pacemakers for slow symptomatic rhythms
7 Slow rhythms that require pacing
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15 DDD -100% AV Pacing
16 Rate Responsive Pacers Vary the rate of pacing according to the patient s physiologic need
17 Pacemakers All have a set rate of pacing = basic rate Magnet rate = fixed or non demand pacing at a set rate
18
19 Pacemaker Terms Rate Output Sensitivity Fire Capture Intrinsic rhythm
20 Pacer Responses Mode of response Inhibit = stops pacing when the patient s HR > set rate Trigger = pacing initiated by an event
21 Cardiac Resynchronization Therapy Biventricular Pacing
22 Left Ventricular Remodeling Relatively normal chamber size and geometry Remodeled ventricle Cohn JN, et al. J Am Coll Cardiol. 2000;35:
23
24 Electrical Conduction System
25 Consequences of Remodeling Globular shape of the ventricles Distortion of the mitral and tricuspid valves Results in MR and TR Increased workload and EDV
26 The Dynamics of Heart Failure Heart failure and abnormal enlargement of the heart Mitral and tricuspid regurg Development of LBBB Results in dis-synchrony of ventricular ejection from the right and left heart
27
28 Cardiac Veins
29
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31 Biventricular Pacing Reduces QRS Duration Therapy OFF Therapy ON Lead V3 QRS=160 ms QRS=120 ms
32 Case Presentation 69yo woman with VF arrest, ICD implanted Idiopathic Cardiomyopathy, LVEF 20%, QRS 180ms 5 years later: Progressive CHF, NYHA Class III, Spironolactone 50mg QD, furosemide 160 BID Zaroxolyn PRN, dig, coreg, zestril, amio, etc. ICD upgraded to BiV pacing DDD ICD
33 Case Presentation 3 months later - unscheduled clinic visit for dizziness: BP 66/50, orthostatic, wgt. loss 10lbs Diuretic dose progressively reduced during subsequent clinic visits over the next 8mos Improving functional status and exercise capacity with EF 35-40% Off zaroxolyn and spironolactone, furosemide dose reduced to 40mg prn Pt walking up to 2miles daily.
34 Internal Cardioverter Defibrillators (ICDs)
35 Fast rhythms that require cardioversion or defibrillation (Ventricular Tachycardia)
36 Rhythms that require defibrillation (Ventricular Fibrillation)
37 In the beginning. Dr. Michael Mirowski identified need in 1960 s Sudden cardiac death syndrome
38 AICD vs ICD
39 A History of Internal Cardioverter Defibrillators The First Generation A shock box only No programmable shocks No back-up pacing
40 A History of Internal Cardioverter Defibrillators The Second Generation Programmable shock Back-up VVI pacing
41 A History of Internal Cardioverter Defibrillators The Third Generation Tiered Therapy Anti-tachycardia Pacing Cardioversion Programmable shock Back-up VVI pacing
42 ICD with leadwire
43 ICD Implantation with Lead Wire
44 Patient Selection LF EF < 40 % (systolic HF) Previous Sudden Cardiac Death Unexplained syncope likely due to VF Previous STEMI (especially Anterior Wall Myocardial Infarction) History of sustained VT
45 ICD Therapies Anti-tachycardia pacing Cardioversion Defibrillation Back-up (post shock) pacing
46 Anti-Tachycardia Pacing Suitability for ATP EP-proven return to SR with ATP VT < 170 beats per minute Monomorphic VT
47 Ventricular Tachycardia converted with ATP
48 Anti-Tachycardia Pacing Advantages Quick treatment delivery Low energy use Painless treatment of VT Well-tolerated by patient
49 Anti-Tachycardia Pacing Disadvantages Ineffective in Polymorphic VT or VF Ineffective for VT at rates > 180 or so Requires Defibrillation backup May accelerate VT to VF
50 Cardioversion Synchronized shock at 2 34 joules up to a certain number of attempts
51 VT converted with cardioversion
52 Ventricular Fibrillation with defibrillation shock
53 VT (rate of 250) with defibrillation
54 VT with cardioversion shock and back-up pacing
55 Magnet Maneuvers Magnets placed over the generator will deactivate the ICD ATP/Defibrillation Once the magnet is removed, the device will resume previous settings and function
56 Troubleshooting ICDs
57 Effects of Drug Therapy = Rate of rhythm too slow ICD therapy based on HR If rhythm is slower than cut-off rate, device will not fire. Plan to reprogram at a lower cut-off rate.
58 Failure of Shocks to Convert Cardiac scarring may effect success ICD malfunction Nursing Implications: Prepare for immediate external defibrillation Do not be afraid to harm the ICD!
59 Inappropriate Shocks Potential Sensing (? double counting) Fast rhythms that are not VT (Afib) Intervention: Prepare to de-activate the device until MD can assess program features Use the magnet to stop shocks!
60 Failure to Shock Rate of rhythm too low ICD may be off or inactive Dysrhythmia may be too short Magnetic interference Sensing lead failure Device will need to be checked for proper functioning
61 VT with ATP causing VF
62 Appropriate Excessive Shocks Increased episodes of VT/VF Medication therapy causing increased VT/VF Nursing Implications Move to ICU Turn device off (magnet) Start IV meds (amiodarone) Sedation
63 Patient Education What to do in case of a shock Describe shock sensation Device follow-up Potential changes in medications Avoid strong magnetic fields Driving implications Lifestyle changes
64 Emotional & Social Concerns Anxiety and fear of shocks Social support/family support Loss of independence Fear of sex or other activities
65 Question Anti-tachycardia Pacing (ATP) has been shown to be successful in the following ICD patient situations: A. Polymorphic VT at rates between190 to 250 B. Inducible VFib C. Monomorphic VT < 170 beats/minute D. Non-inducible tachy-dysrhythmias Answer: C
66 Question The programmed criteria that third & fourth generation defibrillators (ICD) use to decide when to initiate treatment is: A. Body temperature B. Morphology of the QRS complex C. Level of consciousness D. Heart rate Answer: D
67 Question The patient with an ICD should seek emergency attention if: A. More than one shock felt in 24 hours B. The device has not fired in two days C. The ATP mode is used more than 3 times/day D. A beep sounds near electromagnetic field Answer: A
68 Question True or False The purpose of Cardiac Resynchronization Therapy is to enhance cardiac output by stimulating both ventricles simultaneously. Answer: True
69
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