Icd question

[caligas]

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80 yo for urgent ex lap. CHF, EF 20%. Has ICD. EKG shows atrial paced rhythm at 60.

Interrogation of ICD done by remote interrogation device in pre-op. Rep (well known, smart and very reliable) reviews from home, says patient is “only paced about 60% of time,” all atrial signals are carrying through to ventricle, never paces the ventricle. Says the patient is therefore NOT pacer dependent, no reprogramming needed. Says magnet will prevent shocks but will have NO effect on pacing function, which I knew.

Reasonable conclusion?

 

[zizzer]

I agree with the magnet response, but I'm not sure I agree that he's not pacemaker dependent. What if he has intermittent sinus block or sick sinus syndrome?

 

[pgg]

I'd reprogram it to async mode and take care that the patient's intrinsic rate doesn't exceed the async rate I set, lest R on T ruin my day.

"60% of the time it works every time" might be good enough for the Panther ...

 

[Shimmy8]

I mean if you already have a rep looking at it, I’m assuming you can reporgram it remotely? What’s the downside?

Does magnet for this device not reprogram to asynchronous anyway?

 

[caligas]

I mean if you already have a rep looking at it, I’m assuming you can reporgram it remotely? What’s the downside?

Does magnet for this device not reprogram to asynchronous anyway?

Don’t think they can program remotely, only review.

No, magnet for ICD generally only suspends shocks.

 

[pgg]

Does magnet for this device not reprogram to asynchronous anyway?

The pacing function of an ICD is never affected by magnet placement.

 

[drmwvr]

You need pads on the patient anyway. If there were significant bovie interference if and when he were paced, you could temporarily pace him out of it. Setting to asynch atrial pacing doesn't risk an R on T, so that would be a reasonable choice too.

 

[caligas]

The pacing function of an ICD is never affected by magnet placement.

Well....As my high school math teacher used to say in her deep southern drawl, “Never is a long time.”

 

[T-burglar]

He’s pacing 60% of the time because his sinus rate drops below the pacing threshold, not because he’s in unstable bradyarryyhmia 60% of the time . So it’s reasnable to say he’s not pacer dependent. No reprogramming necessary for an ex lap that will most likely be a mild procedure. If the surgery goes sideways he will most likely become tachycardic and the pacing function will be irrelevant.

 

[caligas]

He’s pacing 60% of the time because his sinus rate drops below the pacing threshold, not because he’s in unstable bradyarryyhmia 60% of the time . So it’s reasnable to say he’s not pacer dependent. No reprogramming necessary for an ex lap that will most likely be a mild procedure. If the surgery goes sideways he will most likely become tachycardic and the pacing function will be irrelevant.

That’s pretty much what the rep was saying.

 

[deleted875186]

Agree with everything said. He’s probably Brady at times and is A paced. I would feel comfortable puttin a magnet on.

Another question for you all. You place a magnet on a patient with an ICD for primary prevention due to low EF. Do you always place pads on the patient? What if it’s a quick and very low risk procedure, like a hernia or something?

 

[nimbus]

Agree with everything said. He’s probably Brady at times and is A paced. I would feel comfortable puttin a magnet on.

Another question for you all. You place a magnet on a patient with an ICD for primary prevention due to low EF. Do you always place pads on the patient? What if it’s a quick and very low risk procedure, like a hernia or something?

No. I figure I can remove the magnet if necessary.

 

[Hork Bajir]

Had an EP tech once deactivate an ICD for me, then look at me and say “you are the ICD now”. The point being, the patient should be in a closely monitored setting with pads on until the ICD function gets turned back on. Can you break that rule and take the pads off for a little bit? Sure. Will you get away with that most of the time? Sure. Like everything else in life, you can break the rules as long as you know the risks and are willing to accept the consequences.

With that being said, a patient with low EF having a minor operation who has never gotten any shocks is a different story from a patient with a history of malignant arrhythmia, prior shocks from their device, and high risk surgery.

 

[Hork Bajir]

No. I figure I can remove the magnet if necessary.

Aren’t there some devices where putting a magnet on and taking it off resets some of the parameters? IE you can’t really count on the ICD function after placing a magnet until the device has been reprogrammed? Correct me if I’m wrong...

 

[caligas]

Aren’t there some devices where putting a magnet on and taking it off resets some of the parameters? IE you can’t really count on the ICD function after placing a magnet until the device has been reprogrammed? Correct me if I’m wrong...

You are correct theoretically, but rep never wants to come back and interrogate post op.

 

[Mman]

He’s pacing 60% of the time because his sinus rate drops below the pacing threshold, not because he’s in unstable bradyarryyhmia 60% of the time .

How do we know that his bradycardia isn't making him unstable 60% of the time except for the pacemaker being there? He never gets bradycardic because the pacemaker fires off an atrial beat before he can become bradycardic. But I don't think we can say that he'd be totally fine even without the pacemaker during those times.

 

[T-burglar]

How do we know that his bradycardia isn't making him unstable 60% of the time except for the pacemaker being there? He never gets bradycardic because the pacemaker fires off an atrial beat before he can become bradycardic. But I don't think we can say that he'd be totally fine even without the pacemaker during those times.

It’s just very unlikely given that it’s an ICD (wasn’t placed for symptomatic bradyarrhythmias) and that roughly half the time his own sinus rate overdrives the safety VVI on his ICD. Id bet lots of money that his sinus rate when he’s paced is just below 60. The rep PROBABLY would have mentioned things like heart block intermittently in the device interrogation .

 

[drmwvr]

It’s just very unlikely given that it’s an ICD (wasn’t placed for symptomatic bradyarrhythmias) and that roughly half the time his own sinus rate overdrives the safety VVI on his ICD. Id bet lots of money that his sinus rate when he’s paced is just below 60. The rep PROBABLY would have mentioned things like heart block intermittently in the device interrogation .

But the OP states the patient is currently in AAI. That would be unusual if it were just an ICD as the backup pacer lead us usually just a V lead, no?

 

[psychbender]

But the OP states the patient is currently in AAI. That would be unusual if it were just an ICD as the backup pacer lead us usually just a V lead, no?

Depends. If implanted for severely reduced LV systoluc function from ischemic cardiomyopathy, then there is almost certainly some component of at least impaired relaxation, making pure V-pacing less ideal than having some atrial component to aid in filling. All pts I've anesthetized for ICDs in this setting got both atrial and ventricular leads.

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[drmwvr]

Depends. If implanted for severely reduced LV systoluc function from ischemic cardiomyopathy, then there is almost certainly some component of at least impaired relaxation, making pure V-pacing less ideal than having some atrial component to aid in filling. All pts I've anesthetized for ICDs in this setting got both atrial and ventricular leads.

Less common for me, but in those cases where there needs to be more than just back up ICD pacing (for the reasons you describe) I'm more familiar with biventricular pacing over dual chamber..for whatever that's worth...in the end though, in the OP patient, the presenting mode is AAI only which suggests (to me anyway) that there is an underlying bradyarrythmia without conduction blockade.

 

[vector2]

But the OP states the patient is currently in AAI. That would be unusual if it were just an ICD as the backup pacer lead us usually just a V lead, no?

Most ICDs implanted in the US today are dual chamber, but it can still vary frequently from place to place and EP to EP so it’s obviously best to check.

Google Image Result for https://www.researchgate.net/profile/Tomas_Holubec/publication/283046217/figure/fig4/AS:286936087449603@1445422302522/A-preoperative-chest-x-ray-showing-two-leads-of-a-dual-chamber-ICD-system-with-a-lead.png

A backup rate of 60 may be ok for a normal ventricle, but I would bet that his cardiac index at 60bpm is inadequate for his metabolic demands depending on what kind of abdominal disaster he’s going to surgery for.

 

[anbuitachi]

80 yo for urgent ex lap. CHF, EF 20%. Has ICD. EKG shows atrial paced rhythm at 60.

Interrogation of ICD done by remote interrogation device in pre-op. Rep (well known, smart and very reliable) reviews from home, says patient is “only paced about 60% of time,” all atrial signals are carrying through to ventricle, never paces the ventricle. Says the patient is therefore NOT pacer dependent, no reprogramming needed. Says magnet will prevent shocks but will have NO effect on pacing function, which I knew.

Reasonable conclusion?

Yes. 60% is not dependent.

 

[Iso4ane]

To keep it as as simple as possible, it is possible to be even 90%+ paced, but be NOT pacer dependent.

The key is the underlying rhythm and hemodynamic stability. It is possible for the patient to be naturally bradycardiac and still be hemodynamically stable, so if it’s in an AAI or DDD mode, the pacemaker function does not need to be placed into an asynchronous mode. Even if there is Bovie interference the heart will still be beating.

 

[nlax30]

But the OP states the patient is currently in AAI. That would be unusual if it were just an ICD as the backup pacer lead us usually just a V lead, no?

OP stated atrial paced rhythm on presentation, not AAI mode. It’s a dual chamber ICD so I can guarantee you it’s not AAI mode. A DDD pacer/ICD can still JUST pace the atrium and allow native AV node conduction if it’s intact. So programmed DDD (able to sense and pace both chambers) but may only pace the atrium when intrinsic sinus rate falls below lower rate that’s set and there’s intact AV node conduction.

I agree in that I wouldn’t call this guy pacer dependent (usually reserved for when they are dependent on ventricular pacing...)

Lower rate of 60 is slightly odd in a primary prevention ICD but we don’t have any other details. When interrogating these we usually also inhibit to see what the underlying rate is.

 

[caligas]

OP stated atrial paced rhythm on presentation, not AAI mode. It’s a dual chamber ICD so I can guarantee you it’s not AAI mode. A DDD pacer/ICD can still JUST pace the atrium and allow native AV node conduction if it’s intact. So programmed DDD (able to sense and pace both chambers) but may only pace the atrium when intrinsic sinus rate falls below lower rate that’s set and there’s intact AV node conduction.

I agree in that I wouldn’t call this guy pacer dependent (usually reserved for when they are dependent on ventricular pacing...)

Lower rate of 60 is slightly odd in a primary prevention ICD but we don’t have any other details. When interrogating these we usually also inhibit to see what the underlying rate is.

Yes. all correct.

 

[caligas]

Also want to add how frustrating it is to be the only person in the building with any understanding or interest in the safety of the patient in regards to the ICD. Patient was quite stable pre op, yet I had nurses, surgeons, even CRNA telling me to “just put a magnet on it and let’s go” before gathering any info about the device.

 

[Iso4ane]

Also want to add how frustrating it is to be the only person in the building with any understanding or interest in the safety of the patient in regards to the ICD. Patient was quite stable pre op, yet I had nurses, surgeons, even CRNA telling me to “just put a magnet on it and let’s go” before gathering any info about the device.

In this day and age it’s not so so simple as anymore. Plus, I’m an ICD a magnet is not gonna touch the pacemaker.

 

[drmwvr]

OP stated atrial paced rhythm on presentation, not AAI mode. It’s a dual chamber ICD so I can guarantee you it’s not AAI mode. A DDD pacer/ICD can still JUST pace the atrium and allow native AV node conduction if it’s intact. So programmed DDD (able to sense and pace both chambers) but may only pace the atrium when intrinsic sinus rate falls below lower rate that’s set and there’s intact AV node conduction.

I agree in that I wouldn’t call this guy pacer dependent (usually reserved for when they are dependent on ventricular pacing...)

Lower rate of 60 is slightly odd in a primary prevention ICD but we don’t have any other details. When interrogating these we usually also inhibit to see what the underlying rate is.

So he's A pacing one way or the other at 60 which was my point (with a fail for not nuancing the setting). The speculation was as to why and if there is no answer, dependent or not, do you have the rep come in and reprogram for asynchronous?