ICD question/Case tomorrow

[pgg]

You know exactly what the magnet does if they haven't changed the programming. The magnet can activate different things when programmed to do it. You could look to see what the most recent interrogation says regarding this. Or you could interrogate it yourself. It is not hard to do. We keep some machines to do exactly this for PM/ICD's. Although the report can read like a bad EMR that is 20 pages long.

Yeah ...

I did this in fellowship. I'm not going to do it myself now. I can, but there's just no upside and plenty of potential to screw things up.

The device rep or cardiology or some qualified tech can do it. If it's an emergency, most of the time a magnet is the right answer, with interrogation scheduled for postop.

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[FiO2@21]

With the Pacemaker app it's super easy to get a call back from a rep with the exact settings and programmed behaviors following magnet placement. Able to do that during a turnover at a private practice setting.

But my understanding is that magnets for AICDs with the pacemaker function do absolutely nothing to the pacemaker and just inhibit the defibrillator. So the pacemaker could still detect the EMI and stop pacing the patient.

Had a couple AICD patients who were pacemaker dependent for cases above the umbilicus. Was able to convince the surgeons to use Harmonic each time. I'm sure there will be a case where that won't be feasible/surgeon refuses requiring me to get a rep to drive in and reprogram it to an asynchronous mode. On a good day the pre-op nurses would catch that and call the next patients in early. On a bad day... the surgeon should be grateful the case is happening at all.

 

[Robotic Wis-Hipple]

Good discussion here.

I’ll add my opinion to those that despite being able to check a few boxes on the programmer to do this myself I would not. I’m not sure the addition of liability is worth it. If it’s an urgent case the magnet is the answer 99% of times and if elective it’s not my job to think about the device in a patient the surgeon booked and let them 100% off the hook to even consider it, we’ve got to get them trained…. 😉

Regarding a CRT device, just a point, they’re functionally pacemaker dependent but most truly aren’t actually pacemaker dependent. So, if the case was above the umbilicus and you reprogrammed them to asynchronous mode I’d expect a drop in effective SV and therefore CO. Whereas if you elect to convince the surgeon to use bipolar or it’s a case where they think short monopolar runs will suffice/be possible I may not reprogram at all. In that case an EMI interfered beat would likely be sinus, it would likely provide a better SV than an asynchronous V paced ejection, and BiV pacing would resume once cautery is halted.

The answer per HRS is bipolar or reprogram. Just know in the CRT patients like this one their EF and CO may suffer quite a bit.

 

[Beeftenderloin]

Good discussion here.

I’ll add my opinion to those that despite being able to check a few boxes on the programmer to do this myself I would not. I’m not sure the addition of liability is worth it. If it’s an urgent case the magnet is the answer 99% of times and if elective it’s not my job to think about the device in a patient the surgeon booked and let them 100% off the hook to even consider it, we’ve got to get them trained…. 😉

Regarding a CRT device, just a point, they’re functionally pacemaker dependent but most truly aren’t actually pacemaker dependent. So, if the case was above the umbilicus and you reprogrammed them to asynchronous mode I’d expect a drop in effective SV and therefore CO. Whereas if you elect to convince the surgeon to use bipolar or it’s a case where they think short monopolar runs will suffice/be possible I may not reprogram at all. In that case an EMI interfered beat would likely be sinus, it would likely provide a better SV than an asynchronous V paced ejection, and BiV pacing would resume once cautery is halted.

The answer per HRS is bipolar or reprogram. Just know in the CRT patients like this one their EF and CO may suffer quite a bit.

I’m not sure I agree with this assessment. Patients get put on CRT because they have significant ventricular conduction delays and lack biV synchrony to the point that it impairs their ventricular filling and cardiac output. These things tend to improve while on CRT.

Now, maybe someone who has been on CRT for a year or 2 and had significant recovery of ventricular function might appear better off without it but that’s just because the CRT did it’s job in aiding in ventricular recovery. But patients who have recently been put on it for a class 1/2 indication or who are decompensated tend to have a improved hemodynamics while on CRT, in my experience.

 

[Robotic Wis-Hipple]

I’m not sure I agree with this assessment. Patients get put on CRT because they have significant ventricular conduction delays and lack biV synchrony to the point that it impairs their ventricular filling and cardiac output. These things tend to improve while on CRT.

Now, maybe someone who has been on CRT for a year or 2 and had significant recovery of ventricular function might appear better off without it but that’s just because the CRT did it’s job in aiding in ventricular recovery. But patients who have recently been put on it for a class 1/2 indication or who are decompensated tend to have a improved hemodynamics while on CRT, in my experience.

I’m pretty sure that’s also what I’m saying. Only that a short bout of EMI disturbance is likely to allow for a sinus beat, sure, likely with conduction delay, but still likely better than a pure asynchronous V paced SV. And then, as I haven’t reprogrammed the device, I get the benefit of the CRT for the duration of the non-bovie interference portions of the case.