Device Interrogation- Pacemakers, ICD and Loop Recorders. Dulce Obias-Manno, RN, MHSA, CCDS,CEPS, FHRS Device Clinic Coordinator, MHVI
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1 Device Interrogation- Pacemakers, ICD and Loop Recorders Dulce Obias-Manno, RN, MHSA, CCDS,CEPS, FHRS Device Clinic Coordinator, MHVI
2 Disclosures Consultant: Medtronic Speaker s Bureau: St. Jude Medical
3 Cardiac Implantable Electronic Pacemaker Devices
4 ICD Cardiac Implantable Electronic Devices
5 ILR Cardiac Implantable Electronic Devices
6 Cardiac Implantable Electronic Trends Devices ICDs: Expanding Indications for implantation Pacemaker: Increasing co-morbid conditions
7 Expanding Indications 2006 ACC/AHA/ESC Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death. Circulation. 2006;114: ACC/AHA/HRS Guidelines for Device-Based Therapy. Circulation. 2008;117: ACC/AHA Guideline for the Management of Heart Failure. Circulation. 2013;128:e240 e ACC/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. Circulation. 2013;127:e362 e425
8 Expanding Indications 2014 HRS/ACC/AHA Expert Consensus Statement on the Use of Implantable Cardioverter-Defibrillator Therapy in Patients Who Are Not Included or Not Well Represented in Clinical Trials Circulation. 2014;130:94-125
9 Charleston Comorbidity Index pacemaker population CCI > VVI 14.1% 45% DDD 13.5% 42.4% Greenspon A JACC Vol. 60, No. 16, 2012
10 Device Clinic: Device Interrogation Clinical and Technical Effectiveness Safety and Education
11 Clinician: Device Interrogation Clinical Effectiveness Impact on co-morbid conditions
12 Presenting rhythm
13 Presenting rhythm
14 Settings (Parameters)
15 Intrinsic amplitude (mv) P wave: measurement of intrinsic atrial signal R wave: measurement of intrinsic ventricular signal
16 Ventricular undersensing Ventricular oversensing
17 Atrial undersensing Atrial oversensing
18 Lead status: Fracture Insulation breach Threshold Impedance
19 Lead status: Lead chatter EMI
20 Observations: Arrhythmia events Percent paced Histogram Red alert conditions
21 Observations: Arrhythmia events Correlate clinical symptoms to arrhythmia occurrence Assess response to antiarrhythmic therapy
22 Observations: Arrhythmia events Determine severity of arrhythmia vis-à-vis need for intervention Minimize ICD shocks
23 Minimizing ICD Shocks Vern Hsen Tan et al. Circ Arrhythm Electrophysiol. 2014;7:
24 Minimizing ICD Shocks Conventional programming VF detection: 1 sec VT detection: 2.5 secs 12 of 16 SVT discrimination: ATP therapy: bpm Therapy reduction programming* VF detection: 60 sec VT detection: 6-12 secs 30 of 40 SVT discrimination: ATP therapy bpm 2015 HRS/EHRA/APHRS/SOLAECE expert consensus statement on optimal implantable cardioverter-defibrillator programming and testing *for primary prevention
25 INCIDENCE Appropriate and Inappropriate Shocks 30% 25% 20% 15% 10% 5% 0% Appropriate Shock Inappropriate Shock : Physician discretion or 1 zone shock only : Shock reduction strategies: extended delay, high rate, discriminators, ATP Daubert JP, et al. JACC 2008; 51: Bardy GH,et al. SCD-HeFT. NEJM 2005; 352;3: Saxon, LA et al. Circulation 2006; 114; Saxon LA et al. Circulation 2010; 122: Wilkoff B, et al. JACC 2008; 52: Gasparini,M, et al. JAMA 2013; 309: Moss, A, et al. NEJM 2012; 367:
26 Observations: Percent paced Minimizing RV pacing Effect of pacing mode on incidence of Afib Healey, et al. Circulation. 2006;114:11-17.
27 Observations: Percent paced Minimizing RV pacing Effect of pacing mode on incidence of stroke Healey, et al. Circulation. 2006;114:11-17.
28 Observations: Percent paced Minimizing RV pacing Courtesy of Medtronic Inc Loss of conduction Back-up V-pace
29 Observations: Percent paced Maximizing BiV pacing 2015 HRS/EHRA/APHRS/SOLAECE expert consensus statement on optimal implantable cardioverter-defibrillator programming and testing
30 Observations: Lung impedance Ave v rate Fluid index
31 Observations: Histogram provides a quick look at median and range of HR
32 Observations: Need for rate response Diagnose chronotropic incompetence Correlate with activity level
33 Voltage: battery status
34 Evaluation (final): Appropriate? Normal function?
35 And let s not forget the patient Pocket appearance Good Bad Ugly
36 And let s not forget the patient Deactivating CIEDs in terminally ill patients CRT non-responders Life with a CIED
37 Take away points Device interrogation provides a myriad of data A clinician s focus clinical effectiveness Impact on co-morbidities Qol issues
38 Thank you!
39
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