Cardiac Electrophysiology

Transcription

1 Cardiac Electrophysiology Tamara Langeberg, CNP Minneapolis Heart Institute Cardiac Electrophysiology February 27, 2018 Disclosures None 2

2 Objectives Rhythm identification Identify indications for cardiac monitoring Identify appropriate cardiac monitor to use Devices (pacemaker, defibrillator, biventricular pacemaker, LINQ, Micra, Watchman) Understand indications for device placement Understand the importance of anticoagulation needs pre and post procedure Cardioversions Improve understanding of cardioversion procedure Update anticoagulation recommendations pre/post cardioversion procedure Ablations 3 Cardiac Electrophysiology Rhythm identification Monitoring options Devices (pacemaker, defibrillator, biventricular pacemaker, LINQ, Micra, Watchman) Cardioversions Ablations 4

3 Break Down on Indications for Patient Monitoring Arrhythmia Identification/Burden Correlation of symptoms and arrhythmia Rhythm identification for best management Arrhythmia burden Including post ablation and risk stratification for anticoagulation Cryptogenic stroke (ESUS) Syncope, unexplained 5 Monitors Options: Holter Monitor External Loop Recorder (Event monitor) Patch Monitor APP Implantable Loop Recorder Choice of monitoring used is based on: Frequency of patient symptoms, events Indication for monitoring (syncope, arrhythmia burden, symptoms vs no symptoms, etc.) Patient and provider preference 6

4 Holter Monitor Symptoms frequent enough to be detected within hours of monitoring Most effective if patients are able to record a diary to correlate symptoms/events with possible arrhythmia. 24 hour ambulatory monitoring ~25 to 50% will experience a symptom 2 15% will correlate with causal arrhythmia 35% will not be associated with arrhythmia 7 Event Monitor (external loop monitor) Symptoms that are likely to occur within 1 4 week period of time Patients with abrupt syncope may have limited findings due to lack of patient activation if cardiac arrhythmia is etiology of event, then device auto trigger criteria should correlate with time of patient event Extended monitoring increases symptom detection ~50% at 3days ~75% at 5 21 days (mean 9 days) 8

5 Patch Monitor Can be considered as an alternative to event monitor (2 4 weeks) Products typically accurately self applied Water resistant Have been considered more comfortable and less cumbersome than an event monitor Limited to 1 lead view Holter/Event monitors have at least 3, up to 12 leads 9 There s an App for That >90% of American adults own a cell phone (349.9 million in U.S.) 81% are a smartphone 648,000,000 minutes are spent each month on Facebook! Healthcare systems and providers have been slow to adopt EMRs and integrate medical data with mobile devices Alivecor and ECG Check systems are FDA approved Single bipolar lead (lead I) ECG monitoring systems that snaps on the back of a smartphone Finger contact on the case of the smartphone activates ECG recording Data is transmitted to the smartphone from the case using frequency modulation of an ultrasound or Bluetooth signal Can be viewed in real time Can be transmitted to a secure server for the patient s provider to review in PDF format. The system has been validated in a number of settings, including event monitoring and screening of atrial fibrillation Circulation. 2014;130: Originally published August 11,

6 Implantable Loop Recorder Symptoms occur less than once per month (recurrent, infrequent) Cryptogenic stroke Crystal AF trial with average of 84 days to detection of afib post cryptogenic stroke Unexplained syncope Suspected atypical reflex syncope with or without structural heart disease Example: malignant vasovagal with severe cardio inhibition PICTURE registry (largest study that ILR placed for syncope) 570 patients followed for at least 1 year or until syncopal event (mean of 10 +/ 6 months). Found that syncopal event directly contributed to a diagnosis in 78% of patients. A cardiac etiology was found in 75% of those patients 11 Atrial Fibrillation Term Definition AF that terminates spontaneously or with Paroxysmal AF intervention within 7 d of onset. Episodes may recur with variable frequency. Persistent AF Continuous AF that is sustained >7 d. Long standing persistent AF Continuous AF >12 mo in duration. The term permanent AF is used when the patient and clinician make a joint decision to stop further attempts to restore and/or maintain sinus rhythm. Acceptance of AF represents a therapeutic attitude on the part Permanent AF of the patient and clinician rather than an inherent pathophysiological attribute of AF. Acceptance of AF may change as symptoms, efficacy of therapeutic interventions, and patient and clinician preferences evolve. AF in the absence of rheumatic mitral Nonvalvular AF stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair. 12

7 Not Atrial Fibrillation Atrial Flutter typical, atypical, right sided, left sided 13 Supraventricular Tachycardia Atrial Tachycardia left and/or right sided 14

8 More SVT. WPW, accessory pathway, AV node re entry tachycardia 15 Cardiac Electrophysiology Rhythm identification Monitoring options Devices (pacemaker, defibrillator, biventricular pacemaker, Micra, Watchman) Cardioversions Ablations 16

9 Indications Pacemaker Symptomatic bradycardia (sinus node or AV nodal disease) Micra Pacemaker Symptomatic bradycardia in patient with AV nodal disease, typically chronic atrial fibrillation, high infection risk Defibrillator Primary vs Secondary prevention of sudden cardiac death (SCD) Biventricular (pacemaker or defibrillator) Re synchronization of ventricles to reduce CHF symptoms/hospitalizations and improve LV function Watchman Device newest technology in EP Alternative approach to long term a/c for patients at high cardio embolic event risk and bleed risk 17 Device Options and Leads Used Pacemakers: Dual chamber (atrial AND ventricular) Single chamber (atrial OR ventricular) Biventricular (CRT P) Micra Defibrillators: Dual chamber (atrial AND ventricular) Single chamber (ventricular ONLY) Shocking atrium would cardiovert atrium, shocking ventricle defibrillates ventricle Subcutaneous (single lead, no pacing) Biventricular (CRT D) Watchman (Left Atrial Appendage Occlusion) Device 18

10 What Does a Generator Look Like 19 Leads. Where and What s the Difference 20

11 Pacemaker / ICD 21 Micra Pacemaker Pacemaker placed percutaneously directly into the right ventricle Does not require the use of leads patient s age and medical condition may influence the selection of the Micra pacing system Patient selection: Patient would benefit from a single chamber pacemaker system when placement of a traditional system is difficult

12 Subcutaneous Implantable Cardioverter Defibrillator (SQ-ICD) Used in patients: who are candidates for ICD insertion on the basis of current guidelines who do not have symptomatic bradycardia or spontaneous, recurring ventricular tachycardia (VT) that is reliably terminated with antitachycardia pacing Who may have vascular access challenges Who may be high risk for blood infections New Technologies - EP Patients are candidates for Watchman device if: a CHA 2 DS 2 VASc score of 3 AND Non valvular atrial fibrillation AND Have an appropriate reason to seek a non drug alternative to anticoagulation AND suitable for Warfarin therapy short term

13 Device Placement Considered a minimally invasive procedure Local anesthesia and conscious sedation Pre op antibiotics used (80% reduced infection risk) Transvenous lead placement using subclavian vein, cephalic vein, or axillary vein Generator placed subcutaneously in the infraclavicular region ICDs typically undergo Defibrillation Threshold Test (DFTs) Demonstrates safety margin in the event ICD shock needed Coronary sinus lead: <5% unable to place transvenously placed surgically using a mini thoracotomy (cardiac surgeon) Closed with dissolvable sutures (internal), steri strips or dermabond (over incision) and silverlon dressing (band aide with antimicrobial properties) 25 Pre/Post-Device Anticoagulation Lead Extraction Pacemaker Devices Defibrillators Warfarin Pre procedure Goal INR </= 1.6 for procedure Goal INR for procedure. Goal INR for procedure Post procedure Restart Warfarin the evening post procedure Restart the evening post procedure unless otherwise recommended by EP MD Restart the evening post procedure unless otherwise recommended by EP MD Heparin Pre procedure No heparin products for 6 hours prior to procedure No heparin products for 6 hours prior to procedure No heparin products for 6 hours prior to procedure Lovenox Post procedure Ideally no heparin products post procedure, but if needed, restart IV heparin post procedure based on EP MD recommendations. Ideally no heparin products post procedure, but if needed, restart IV heparin post procedure based on EP MD recommendations. Ideally no heparin products post procedure, but if needed, restart IV heparin post procedure based on EP MD recommendations. None unless EP MD recommends None unless EP MD recommends None unless EP MD recommends 26

14 Intermediate Risk Procedure Devices are considered a simple procedure with intermediate bleed risk, but never without any risk 27 Cardiac Electrophysiology Rhythm identification Monitoring options Devices (pacemaker, defibrillator, biventricular pacemaker, LINQ, Micra, Watchman) Cardioversions Ablations 28

15 Goal of Cardioversion. How? Simple definition: Convert the patient back to a normal rhythm. Chemical: use of medications corvert, Dofetilide, Flecainide, Propafanone, amiodarone, quinidine.. Direct Current: electrical shock Causes depolarization of cardiac cells and allows the sinus node to take back over 29 Cardioversion Procedure Risks Sun burn from patches/energy Bite tongue Obesity Increased tissue to penetrate, airway obstructs easier Stroke/TIA: embolic Highest risk in 48 hours following the procedure Ongoing risk in first month post cardioversion (motion of muscle is not synchronous) 30

16 Pearls Nothing by mouth for 8 hours prior to procedure Must have a driver with them and someone to stay with them for at least 24 hours (Allina policy). We use propofol for sedation patient wakes up asking when we are going to start. Literally out for ~3 5 minutes. Therapeutic anticoagulation 31 Anticoagulation Warfarin with INR >2.0 or on DOAC for at least 21 consecutive days prior to procedure. Day zero starts with first therapeutic INR or first dose of DOAC If sub therapeutic anticoagulation (INR <2.0 or missed/not on Novel agent 21 consecutive days), then patient will need TEE guided cardioversion. If thrombus seen on TEE, then anticoagulation x6 consecutive weeks followed by repeat TEE to document thrombus resolution prior to cardioversion If patient presents with clearly defined onset of arrhythmia <48 hours, then DCCV can be performed without TEE.

17 Wait there s more Treat with anticoagulation for a minimum of 1 month post cardioversion Long term anticoagulation per risk stratification using CHA2DS2 VASc score. Patients who undergo TEE guided DCCV should be therapeutically anti coagulated at the time of TEE guided DCCV. Therapeutic heparin level and continued until INR >2.0 Lovenox 1mg/kg SQ Q12h until INR >2.0 Warfarin with INR >/= 2.0 (for <3 consecutive weeks) Fingerstick INR vs Venous draw INR 33 Cardiac Electrophysiology Rhythm identification Monitoring options Devices (pacemaker, defibrillator, biventricular pacemaker, LINQ, Micra, Watchman) Cardioversions Ablations 34

18 Radiofrequency Ablation (RFA) Heat energy used alters conductibility of cardiovascular tissue. SVT Arrhythmia triggered using pacing and proarrhythmia medication (isuprel) Mapping techniques used to locate origin of arrhythmia Atrial Fibrillation CT or MRI imaging used to create a 3D view of heart and associated structures (pulmonary veins, esophagus) Procedure duration 3 4 hours depending on arrhythmia origin and # of sites Use MAC (conscious sedation) vs general anesthesia depending on procedure complexity Sedation can inhibit our ability to trigger the arrhythmia 35 Ablation Images 36

19 Anticoagulation SVT Persistent Atrial Fib/flutter Paroxysmal Afib/flutter Warfarin Pre procedure None needed Goal INR 2 3 for 3 weeks prior to procedure Goal INR depending on CHADS score Day of Procedure None needed Goal INR TEE if INR <2 in 3 weeks prior to procedure Therapeutic INR not necessary. Hold warfarin 3 days prior. +/ TEE if in afib/flutter Post procedure None needed Continue x8 weeks, then depending on CHADS2 score Continue x8 weeks, then depending on CHADS2 score Heparin Pre procedure None needed No heparin products (IV or SQ) for No heparin products (IV or SQ) for 6 hours prior to procedure. 6 hours prior to procedure. Post procedure If needed, based on EP MD recommendations. If needed, based on EP MD recommendations. Lovenox Post procedure None needed Based on EP MD Based on EP MD recommendations when INR <2.0, recommendations when INR <2.0, 1/2 dose Q12hours 1/2 dose Q12hours Ablation Procedure Risks Damage to normal conduction Resulting in need for pacemaker placement Cardiac perforation/tamponade Requiring pericardial drain placement Femoral access site bleeding, infection Rarely can have pseudo aneurysm (less common in venous access sites) Esophageal Perforation/Ulceration Life threatening (50% mortality risk) 38

20 US Dairy Council: 7% of American adults believe chocolate milk comes from brown cows = 16.4 mil Americans 39