Tachycardia Devices Indications and Basic Trouble Shooting

Transcription

1 Tachycardia Devices Indications and Basic Trouble Shooting Peter A. Brady, MD., FRCP Cardiology Review Course London, March 6 th, MFMER

2 Tachycardia Devices ICD Indications Primary and Secondary SCD prevention Cardiomyopathy: HCM and ARVC Channelopathies LQT, Brugada Syndrome Basic programming and ICD function Basic troubleshooting 2011 MFMER

3 CP MFMER

4 Sudden Cardiac Death Prevention Secondary SCD prevention SCD survivors, documented sustained VT/VF, syncope with inducible VT Recurrence 20-40% in 1 year 2011 MFMER

5 Secondary SCD Prevention ICD Trials Study Year Pt (no.) Underlying disease (EF) Inclusion Mean age Follow-up All cause mortality p AVID ,016 ICD vs AAD CAD 81% (EF: ICD group 0.32±0.13; AAD group 0.31±0.13) SCD survivors/vf VT + syncope VT + EF 0.40 ICD group: 65±11 yrs AAD group: 65±10 yrs Follow-up: 18.2±12.2 mo <0.02 CIDS ICD vs amiodarone CAD: ICD group 82.9%; amiodarone group 82.2% (EF: ICD group 0.34±0.15; amiodarone group 0.33±0.14) VF; OHCA VT + syncope VT + EF 0.35 Syncope + inducible VT ICD group: 63.3±9.2 yrs Amiodarone group: 63.8±9.9 yrs Follow-up: 2.9±3.0 yrs (NS) CASH ICD vs amiodarone vs metoprolol CAD 73% (EF: 0.46±0.19) SCD survivors with documented VT or VF (84%) 58±11 yrs Follow-up 57±34 mo (NS) 2011 MFMER

6 Recommendations for ICD Secondary Prevention Class I Survivors of cardiac arrest due to VFib or hemodynamically unstable sustained VT after evaluation to define the cause of the event and to exclude any completely reversible causes (LOE: A) Reversible: drugs/proarrhythmia, ablatable arrhythmias in normal heart (WPW), polymorphic VT/VF within 48 hrs of MI, electrolyte abnormalities Structural HD and spontaneous sustained VT, whether hemodynamically stable or unstable (LOE: B) Device Guidelines: JACC 51(21):2085, 2008 CP MFMER

7 Recommendations for ICD Secondary Prevention Class III An expectation of survival with an acceptable functional status for <1 year (level of evidence: C) Incessant VT or VFib (level of evidence: C) Significant psychiatric illnesses that may be aggravated by device implantation or that may preclude systematic follow-up (level of evidence: C) NYHA class IV pt who are not candidates for cardiac transplantation or implantation of a CRT device that incorporates both pacing and defibrillation capabilities (level of evidence: C) Syncope of undetermined cause in pt without inducible ventricular tachyarrhythmias and without structural HD (level of evidence: C) A completely reversible disorder in the absence of structural HD (eg, electrolyte imbalance, drugs, or trauma) (level of evidence: B) CP MFMER

8 Sudden Cardiac Death Prevention Primary SCD prevention Patients with known underlying heart disease with increased risk of SCD Risks vary depending on the severity of myocardial dysfunction and other markers 2011 MFMER

9 ICD in SCD Primary Prevention Study Year MADIT 1996 CABG- Patch 1997 MUSTT 1999 MADIT-II 2002 SCD- HeFT 2005 Pt. No. 196 ICD vs medical therapy 900 ICD vs medical therapy 704 EP guided therapy (ICD or AAD) vs no AAD 1,232 ICD vs medical therapy 2,521 ICD vs amiodarone vs medical therapy Underlying Disease (EF) Prior MI NSVT CAD/MI +SA-ECG CAD/MI NSVT CAD/MI CAD (52%) DCM (48%) Inclusion EF 0.35 Inducible VT or VF, not suppressible by procainamide EF 0.35 All had CABG as the standard therapy EF 0.40 Inducible VT EF 0.30 (excluded class IV CHF; MI <1 month; high likelihood of death during trial) EF 0.35 NYHA II (70%) III (30%) Mean Age Follow-Up Inclusion yrs ICD: 62 ± 9 yrs Medical therapy: 64 ± 9 F/U: 27 months Excluded 80 yrs (5% of screened); ICD: 64 ± 9 yrs Medical therapy: 63 ± 9 F/U: 32 ± 16 months Mean (25%, 75%), 67 (59,72) yrs; 17/704 (2%) >80 yrs; F/U: 39 months >21 yr, no upper limit; Mean 65 ± 10 yrs (range 29-88); 436 (35%) 70 yrs F/U: 20 months ICD: median 60.1 years Amiodarone: median 60.4 years Medical therapy: median 59.7 years F/U: median 45.5 months All Cause Mortality (ns) 0.06 (EP guided therapy vs no AAD); <0.001 ICD vs no ICD ICD vs medical therapy Amiodarone vs medical therapy 2011 MFMER

10 ICD After Myocardial Infarction Study Year Pt. No. Underlying Disease (EF) Inclusion Mean Age Follow-Up All Cause Mortality DINAMIT ICD vs medical therapy CAD MI 6-40 days EF 0.35 Abnormal HRV Inclusion: yrs ICD: 61.5 ± 10.9 yrs FU: 30 ± 13 months <0.66 (ns) IRIS ICD vs medical therapy CAD MI 5-31 days EF HR 90 bpm or NSVT ICD group = 62.8 ± 10.5 years Medical group: 62.4 ± 10.6 yrs FU: 37 months 0.78 (ns) Do Not Recommend ICD within 40 Days of MI 2011 MFMER

11 ICD and SCD in CAD and IDCM Primary Prevention Key Points Underlying disease Ischemic, non-ischemic, other conditions EF and functional class 35%, NYHA II and III: class I (A) 30%, NYHA I, ischemic: class I (A) 35%, NYHA I, non-ischemic: class IIb (C) 40%, NSVT, ischemic, inducible VT/VF: class I (B) NYHA IV, no stand-alone ICD indication Timing to MI: > 40 days CP MFMER

12 ICD in Hypertrophic Cardiomyopathy Prior cardiac arrest or Sustained VT No Family Hx SD in 1 relative or LV wall thickness 30 mm or Recent unexplained syncope No Yes Yes ICD recommended ICD reasonable Nonsustained VT or Abnormal BP response Yes Other SCD risk modifiers present No ICD not recommended Legend Class I Class IIa Class IIb Class III Yes No ICD can be useful Role of ICD uncertain Gersh et al: JACC 58:e212, 2011

13 ICD in Long QT and Brugada Syndromes Long QT Syndromes Brugada Syndrome Prior cardiac arrest? Yes ICD recommended Prior cardiac arrest or Sustained VT? Yes ICD recommended No Recurrent syncope while on beta blocker? Yes ICD can be useful No Spontaneous type I ECG and Hx of syncope judged to be caused by vent arrhythmias? Yes ICD can be useful No Asymptomatic not treated with beta blockers? Yes ICD not indicated Inducible VF on EP study? Yes ICD may be considered No recommendation: Syncope off beta blocker Priori et al: HRJ, 2013 Legend Class I Class IIa Class IIb Class III Asymptomatic with drug induced type I ECG and family Hx of SCD? No or no EP study Yes ICD not indicated

14 ICD Review: Objectives Who needs an ICD Secondary SCD prevention, CAD, IDCM Primary SCD prevention, CAD, IDCM HCM, LQT, Brugada syndromes Basic programming and ICD function Basic troubleshooting 2011 MFMER

15 Far Field and Near Field Electrograms

16 Stored ICD Electrograms and Markers A V-N V-F 2011 MFMER

17 Antitachycardia Pacing Stops VT 2011 MFMER

18 VF Terminated with High Energy Shock 2011 MFMER

19 ICD Effect of Magnet Application Magnet disables ICD rhythm detection and shocks Pacing typically not affected Clinical: Magnet application stops / prevents inappropriate ICD therapies (shocks) without affecting pacemaker function Always re-interrogate ICD function after magnet is used

20 ICD Review: Objectives Who needs an ICD Secondary SCD prevention, CAD, IDCM Primary SCD prevention, CAD, IDCM HCM, LQT, Brugada syndromes Basic programming and ICD function Basic troubleshooting 2011 MFMER

21 ICD Discharge Tachyarrhythmia No tachyarrhythmia (oversensing) SVT/AF (inappropriate detection) VT/VF (appropriate detection) Intracardiac signals P or T waves Extracardiac signals Fracture, MP, EMI 2011 MFMER

22 ICD Interrogation After Shock 2011 MFMER

23 Inappropriate Therapy SVT/Atrial Tachycardia Atrial Ventricular 2011 MFMER

24 Inappropriate Discharge Due to AT/SVT/AF Solutions Treat AT/SVT/AF AV node blocking agents, membrane active drugs RF ablation of AT/SVT/AF or AV node Reprogram ICD to multizone with therapy inhibitors active in lowest zone (tachycardia onset or stability) Upgrade ICD from single to dual chamber pacing/sensing (AV relationship) 2011 MFMER

25 ICD Discharge Tachyarrhythmia No tachyarrhythmia (oversensing) SVT (inappropriate detection) VT/VF (appropriate detection) Intracardiac signals P or T waves Extracardiac signals Fracture, MP, EMI 2011 MFMER

26 ICD Troubleshooting Lead Fracture 2011 MFMER

27 Lead Fracture Evaluation and Management Check pacing thresholds, impedance and CXR High impedance = conductor fracture Low impedance = Insulation break Program ICD to monitor only mode Provocative maneuvers (manipulate device in pocket / upper limb movements) to try and reproduce noise 2011 MFMER

28 ICD Troubleshooting Myopotentials Initial Detection VF zone Pre-attempt Avg Rate MFMER

29 ICD Troubleshooting Myopotentials Solutions Place a separate screw-in rate sensing lead in RV Myopotential sensing less common with true bipolar sensing lead vs. integrated bipolar lead where RV is sensed from the tip to the distal coil Distal Coil Tip Distal Coil Ring Tip integrated bipolar sensing lead true bipolar sensing lead 2011 MFMER

30 Electromagnetic Interference Arc Welding Pre-attempt Avg A rate 533 Pre-attempt Avg V rate MFMER

31 Summary Know ICD print out abbreviations Far field versus near field signals ICD discharge Interrogate device Determine appropriate vs. Inappropriate Magnet application prevents recurrent inappropriate shocks till definite therapy Common causes of inappropriate shocks - Fast rate with normal device function - Device/lead dysfunction 2011 MFMER

32 Thank you 2011 MFMER