You’ve Come Along Way u Baby: Pacemakers and uve_come_along_way_ba.pdf8/9/18 1 You’ve Come Along...
Transcript of You’ve Come Along Way u Baby: Pacemakers and uve_come_along_way_ba.pdf8/9/18 1 You’ve Come Along...
8/9/18
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You’ve Come Along Way Baby: Pacemakers and ICDsGLENDA S. DELL MSN, APRN ACNS-BC
TNP CONFERENCE
SEPTEMBER 8, 2018
Objectives
u Participants will learn the history of pacemakers and ICDs.
u Participants will identify MRI compatible pacemakers and ICDs.
u Participants will identify indications for wireless pacemakers and ICDs and implications for care.
u Participants will identify indications for HIS bundle pacing.
Disclosures:
u I have nothing to disclose.
Devices
History
Transcutaneous Pacemaker Portable Pacemaker
History
u October 8th 1958 first implantable pacemaker in Sweden by Senning and Elmvquist.
u Done by thoracotomy and 2 epicardial leads placed.
u Device lasts 3 hours.
u The recipient Arne Larsson survived until 2001(his cause of death was not related to his cardiac issues)
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History
u 1970s Nuclear pacemaker were developed.
u Pacemaker become non-invasively programmable in the mid 1970s.
u Dual chamber devices are developed in the late 1970s.
u The 1980s drug eluding steroid leads, rate response pacing developed.
u The 1990s micro-processor pacemakers appeared
u The 2000’s biventricular pacing introduced.
u 2015 HIS bundle pacing.
History
First pacemaker Pacemakers Today
History
u 1980 the first ICD was implanted by Michel Mirowski and his team.
u Was considered a treatment of last resort.
u Devices were large, performed by open chest surgery.
History
History
Trials MADIT [10] MUSTT [11] MADIT II [13] SCD-HeFT [28]
Sample size 196 704 1232 2521
DesignICD vs antiarrhythmic drugs as conventional therapy
EP-guided therapy vs placebo
ICD vs optimal pharmacological therapy
ICD vs optimal pharmacological therapy vs optimal pharmacological therapy + amiodarone
PatientsPrevious MI, EF ≤ 0.35, nsVT, positive findings on EPS
Coronary disease, EF ≤ 0.40, nonsustained VT, inducible VT at EPS
Prior MI, EF ≤ 0.30
Ischemic and nonischaemic cardiomyopathy, EF ≤ 0.35
Follow-up (months) 27 39 20 46
Results
Risk reduction with ICD 54% (P = 0.001) 51% (P = 0.001) 31% (P = 0.02) 23% (P = 0.007)
History
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History History
MRI Devices MRI Devices:
u MRI conditional devices contain a dedicated MRI pathway.
u Safety features include:
u System integrity checks, Asynchronous pacing, tachy detections disabled, increased output during the scan, return to preprogrammed state.
u Most MR conditional devices use 1.5T scans in “normal operating mode”
u If patient has abandoned or epicardial leads MRI is not recommended.
MRI Devices:
u Identify Patient has an MRI compatible device and leads.
u Verify patient has had the device at least 6 weeks.
u Scheduling will require coordination between radiology and cardiology.
u Device may cause image artifact.
MRI Devices:
u Once scheduled:
u Device clinic staff should be present to test and reprogram device prior to MRI.
u EKG and Pulse Oximetry monitoring should be done throughout the scan.
u Patient’s device should be checked post MRI.
u ILR(implantable loop recorder) should be interrogated pre-MRI.
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MRI Devices: MRI: Devices
MRI Devices:
u Contact information:
u Medtronic: 1-800-551-5544
u Boston Scientific: 1-800-227-3422
u ST Jude/Abbott: 1-800-722-3774
u Biotronik: 1-800-547-0394
MRI Devices: Medtronic
MRI Devices: Boston Scientific MRI: St Jude/Abbott
PacemakersAssurity 1272
Assurity 2272
Confirm implantable Cardiac Monitor.
1.5 T MRI image scans
ICDs/CRT-DEllipse VR
Ellipse DR
Fortify Assura VR
Fortify Assura DR
Quadra Assura CRT-D
1.5T MRI image scans
LeadsLPA1200M
7122Q
1458Q
1.5T MRI image Scans
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Leadless Devices Leadless Devices
u Eliminate/reduce pocket and lead complications seen with traditional pacemakers.
u Safe pacing option for those patients who have had a device infections.
Leadless Devices
u Delivered through a transcutaneous approach.
u 99.1% implant success rate.
u Low dislodgement rate(0.06%)
u Low infection rate (0.17%)
u Retrieval feature for acute retrieval.
u 87% relative risk reduction in system revisions. 54% fewer hospitalizations.
Leadless Devices
Leadless Devices: Leadless Devices:
u Preferred choice for:
u Patients 65 and younger who lead an active lifestyle.
u Have no venous access
u Are diagnosed with Channelopathies(LQT, Burguda, HCM)
u High risk for complications with TV-ICD.
u Have high risk of infections and history of endocarditis.
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Leadless Devices
u Benefits:
u Decreased time limits of range of motion restrictions( 2 weeks vs 4 weeks).
u Implant site reduces visible scarring.
u Reduced chance of infection.
u Less likely to receive inappropriate shock( a fib with rvr)
u Drawbacks:
u Twice as large as a traditional ICD.
u Very thin pt. will not be a candidate.
u NO standard pacing support
u No tachypacing support
Leadless Devices
HIS Bundle Pacing HIS Bundle Pacing
u Long term RV pacing can lead to structural and cellular changes.
u CRT with BIV pacing not always feasible.
u HIS pacing can prevent ventricular dyssynchrony and LV dysfunction.
u Has shown to restore conduction through the diseased HIS-Purkinje system.
HIS Bundle pacing
u Risk and complications:
u High threshold >2.5v/1.0ms (10-15%)
u Lead revisions (~ 3-6.7%)
u Ventricular undersensing
u Far-field atrial oversensing.
u Capturing the atrium
HIS Bundle Pacing
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HIS Bundle Pacing HIS Bundle Pacing
u No history of CAD / CABG / PCI / MI
u 2014: Diagnosed with CHFu TTE 5.15.14: LVEF ~ 35% + Moderate AS (mean PG = 33 mm Hg)
u ECG:
HIS bundle Pacing
u No history of CAD / CABG / PCI / MIu 2014: Diagnosed with CHF
u TTE 5.15.14: LVEF ~ 35% + Moderate AS (mean PG = 33 mm Hg)u ECG: LBBBu Cath (-)
u 2017: Worsening CHF + decreased exercise toleranceu TTE: LVEF ~ 35% + Severe AS (mean PG = 42 mm Hg)u Cath (-)
u TAVR 8.1.17u TTE 8.21.17: TAVR is good; LVEF ~ 35%
HIS Bundle Pacing
HIS Bundle Pacing
u TAVR 8.1.17
u TTE 8.21.17: TAVR is good; LVEF ~ 35%
u CRT-D implanted 9.21.17u TTE 9.22.17: LVEF ~ 40%
u TTE 1.8.18: LVEF = 55%
HIS Bundle Pacing
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HIS Bundle Pacing HIS Bundle Pacing
HIS Bundle Pacing
Patient is symptomatic with this. Next step?
What type of Pacemaker? What % of RV Pacing do you expect?
HIS Bundle Pacing
HIS Bundle Pacing Questions
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Helpful Websites:
u www.medtronicacademy.com
u www.bostonscientific.com
u www.sjm.com
References:
u Aquilina, O. (2006). A brief history of cardiac pacing. Images in Pediatric Cardiology, 8(2),17-81. Retrieved July 15, 2018, from pubmed.gov.
u Boston Scientific. (2017). Cardiac rhythm resource center. Retrieved from http://www.bostonscientific.com
u Chang, P. M., Doshi, R., & Saxon, L. A. (2014). Subcutaneous Implantable Cardioverter Defibrillator. Circulation,129(23), E644-E646. doi:doi.org/10.1161/CIRCULATIONAHA.113.006645
u El-Chami, M. F., MD, Johansen, J. B., MD, Zadai, A., MD, Faerestand, S., MD, Reynolds, D., MD, Garcia-Seara, J., Piccini, J. P., MD. (n.d.). Leadless Pacemaker Implant in Patients with Pre-Existing Infections: Results from the Micra Post-Approval Registry. Retrieved from http://www.medtronic academy.com, August 5, 2018.
u Ellenbogen, K. A., & Vijayaraman, P. (2015). His Bundle Pacing A New Promise in Heart Failure Therapy? Journal of American College of Cardiology, 1(6). doi:10.1016/j.jacep.2015.09.007
u Indik, J. H., Gimbel, J. R., Abe, H., Alkmim-Teixeira, R., Birgersdotter-Green, U., Clarke, G. D., Woodard, P. K. (2017). 2017 HRS expert consensus statement on magnetic resonance imaging and radiation exposure in patients with cardiovascular implantable electronic devices. Heart Rhythm, 14(7). doi:10.1016/j.hrthm.2017.04.025
References:
u Medtronic (2018). Corepace. Retrieved from http://www.medtronicconnect.com
u St. Jude Medical. (2017). Clinical discoveries for healthcare professionals. Retrieved from
http://www.clinical.sjm.com