Pacemakers/AICDs

[Ignatius J]

Cardiologist checked the device, was found to have fired multiple times during case, pt was paralyzed during case

My question was in regards to the patient's heart/EKG strip after the ICD fired, and what the pacemaker subsequently did once that strip was obtained.

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[Ignatius J]

1. I've seen monopolar cautery cause an AICD to discharge several times. That patient's battery life was depleted by 1/3 after the case. No magnet was applied during the case (VAT).

2. I've seen Monopolar cautery cause an AICD to go haywire during a total should replacement. The bovie was about 4 inches from the device and the pacemaker portion of the device malfunctioned. A magnet was applied during the case.

3. I've seen a Monopolar cautery cause a pacemaker to "reprogram itself" with a new rate of 120. That pacemaker required a "reset" to the correct rate of 75.

Case number 2 was cancelled and resecheduled for another date. The pacemaker was set to an asynchronous mode (which it should have been set to in the first place).

Yikes, no magnet or reprogramming during a VATS. That is a no-no.

How long ago was #2 and #3? The newer devices are supposed to be more resistant/not reprogram/malfunction as much to monocautery.

 

[sethco]

Had a patient a couple weeks ago that was added on to my schedule the day of surgery. Put was to be a Redo CABG. Had a single lead on CXR. I asked the patient about it and he said it was a AICD, but did not recall who the manufacturer was and did not carry the card on him. Asked the surgeons PA and he did not know the manufacturer. Called his Cardiologist without any response. After discussing it with surgeon, we decided to go to surgery and put a magnet on and have our reps come in if needed to help. This is not my usual practice. I will usually find out who the manufacturer is, give them a call. Ask them the magnet response and find out if they would like to come by preop. If not, I give them a time frame of when to come by to interrogate the PPM/AICD in the postop period. For this particular patient we put on a magnet and the device discharged a couple of times while the surgeon was using cautery. Called all of our in house reps. Metronic rep was nice enough to come in room and point is in the right direction. Ended up being a Biotronik AICD. I had never seen a Biotronik device, but apparently this particular EP guy has some kind of arrangement with them, so that was the give away. Called the Biotronik rep and he was able to come in and deactivate the anti tachycardia function before coming off pump. So, my lesson was learned. Never assume that the magnet will disable the device and always know the magnet response. Just my two cents

 

[Chloroform4Life]

Some thoughts.....

If the AICD inadvertently goes off, what adverse effect is there beside battery life drainage? The mysteriously elusive R on T phenomenon? I've seen a lot of PVCs in my life superimposed on T waves and have yet to witness one causing v-tach or v-fib.

If the pacemaker oversenses EMI and forgets to pace a beat or two, does it make a difference? The EMI will stop and pacing goes back to normal unless reprogramming occurred.

Reprogramming is getting rarer given technological advances of pacer/aicds. Isn't reprogramming more likely with placement of a magnet?

 

[pjl]

Some thoughts.....

If the AICD inadvertently goes off, what adverse effect is there beside battery life drainage? The mysteriously elusive R on T phenomenon? I've seen a lot of PVCs in my life superimposed on T waves and have yet to witness one causing v-tach or v-fib.

I have seen this during a cardioversion when some joker forgot to sync, on a case in my first few weeks as an attending. It was unpleasant, and took a while to get the poor guy through his code into a sinus rhythm.
I will say that he was the healthiest post-code patient I have ever seen.


Sent from my iPad using SDN mobile app

 

[BLADEMDA]

Yikes, no magnet or reprogramming during a VATS. That is a no-no.

How long ago was #2 and #3? The newer devices are supposed to be more resistant/not reprogram/malfunction as much to monocautery.

These were all "newer" devices. Numbers 2 and 3 occurred in 2010 and 2012 respectively.

 

[BLADEMDA]

Had a patient a couple weeks ago that was added on to my schedule the day of surgery. Put was to be a Redo CABG. Had a single lead on CXR. I asked the patient about it and he said it was a AICD, but did not recall who the manufacturer was and did not carry the card on him. Asked the surgeons PA and he did not know the manufacturer. Called his Cardiologist without any response. After discussing it with surgeon, we decided to go to surgery and put a magnet on and have our reps come in if needed to help. This is not my usual practice. I will usually find out who the manufacturer is, give them a call. Ask them the magnet response and find out if they would like to come by preop. If not, I give them a time frame of when to come by to interrogate the PPM/AICD in the postop period. For this particular patient we put on a magnet and the device discharged a couple of times while the surgeon was using cautery. Called all of our in house reps. Metronic rep was nice enough to come in room and point is in the right direction. Ended up being a Biotronik AICD. I had never seen a Biotronik device, but apparently this particular EP guy has some kind of arrangement with them, so that was the give away. Called the Biotronik rep and he was able to come in and deactivate the anti tachycardia function before coming off pump. So, my lesson was learned. Never assume that the magnet will disable the device and always know the magnet response. Just my two cents

Biotroniks are junk. IMHO, be on high alert when you see a Biotronik device. Highest quality CIEDs are Medtronic and St jude.

 

[Ignatius J]

These were all "newer" devices. Numbers 2 and 3 occurred in 2010 and 2012 respectively.

#2 is interesting that the pacing interfered but the ICD didn't go off.

 

[BLADEMDA]

Boston Scientific Launches World's Longest Lasting ICD
Feb 2, 2015

MARLBOROUGH, Mass., Feb. 2, 2015 /PRNewswire/ -- Boston Scientific Corporation (NYSE: BSX) announces the launch and first U.S. implant of its line of Extended Longevity (EL) implantable cardioverter defibrillators (ICD), including DYNAGEN™ EL and INOGEN™ EL device models. The first EL ICD was implanted at The University of Pittsburgh Medical Center (UPMC) by Dr. Samir Saba. The device features EnduraLife™ battery technology that was developed with high-performance chemistry and advanced manufacturing capabilities to provide up to double the battery capacity of other ICDs. Devices with similar technology have been shown to outperform competitors' device longevities in several recent clinical studies,1,2,3,4 and the EL ICD is projected to last nearly 12 years.5

"Battery longevity has a direct impact on patient outcomes and the cost of care," said Dr. Saba. "The EL ICD is an important advancement that can help minimize the frequency of avoidable replacement procedures to help reduce costs and the potential for replacement-related complications."

The EnduraLife battery technology delivers the industry's longest projected longevity, and is packaged in a device up to 11 percent smaller and 24 percent thinner than devices from other manufacturers6. Increased device longevity can reduce the risk of infection and other complications over time, minimize out-of-pocket patient expenses for avoidable replacement procedures, and decrease other healthcare system costs associated with device therapy. 7,8,9,10

"Boston Scientific is proud to build upon the world's most innovative ICD technology with the world's smallest ICD, the world's longest-lasting ICD and the world's only subcutaneous ICD," said Joe Fitzgerald, executive vice president and president, Rhythm Management. "By providing a device with greater battery capacity, physicians are now able to offer patients a longer lasting device and increased peace of mind, while administrators and payors have new options to more effectively manage healthcare costs and minimize unexpected complications."

 

[Ignatius J]

Some thoughts.....

If the AICD inadvertently goes off, what adverse effect is there beside battery life drainage? The mysteriously elusive R on T phenomenon? I've seen a lot of PVCs in my life superimposed on T waves and have yet to witness one causing v-tach or v-fib.

If the pacemaker oversenses EMI and forgets to pace a beat or two, does it make a difference? The EMI will stop and pacing goes back to normal unless reprogramming occurred.

Reprogramming is getting rarer given technological advances of pacer/aicds. Isn't reprogramming more likely with placement of a magnet?

This is what I am trying to understand. What happens when you defibrillate a patient in NSR in terms of percentages of time they arrest/nothing happens/etc.

 

[BLADEMDA]

#2 is interesting that the pacing interfered but the ICD didn't go off.

Magnet was applied over the AICD which prevented it from discharge. But, the magnet does not turn the pacemaker portion into an asynchronous mode or prevent the bovie from causing interference to the pacemaker function.

 

[BLADEMDA]

This is what I am trying to understand. What happens when you defibrillate a patient in NSR in terms of percentages of time they arrest/nothing happens/etc.

It's rare that anything happens except the patient's device will lose battery strength leading to premature replacement.

 

[BLADEMDA]

Medtronic has 75% of the market:


https://www.medtronic.com/wcm/groups/mdtcom_sg/@mdt/@corp/documents/documents/crdm_sl_magnet_icd.pdf

 

[BLADEMDA]

St Jude:


Magnet Use for SJM Implanted Cardioverter-Defibrillators When a patient with a St. Jude Medical® ICD needs to have his or her high-voltage therapies temporarily disabled for a medical procedure, a magnet may be used as a convenient alternative to temporary programming. Magnet Mode: If the device is exposed to a constant magnetic field of sufficient strength, the tachy sensing circuitry will be temporarily suspended, thereby disabling any tachyarrhythmia detection. Once the magnetic field is removed, arrhythmia detection is again enabled. Magnet application will not affect the bradycardia pacing function; bradycardia pacing will continue as programmed. Unlike the function of a pacemaker, the brady pacing operation of an ICD is not forced to pace asynchronously when exposed to a magnet. A cardiac device magnet can be obtained from the various device manufacturers. The magnet should be placed securely over the device. If the magnet is going to be left on for an extended period of time or during a surgical procedure, the magnet should be securely taped on the patient. Improper magnet placement may hinder magnet activation and could lead to undesired delivery of therapy. Although generally not necessary, high voltage therapies may be indefinitely suspended via temporarily programming to “Tachy Therapy is Disabled” or “Tachy Zones Off” depending on the programmer options for each specific model. It should be noted that ICDs can have their magnet response programmed to IGNORE the placement of a magnet and therefore continue to deliver therapy even if a magnet is properly positioned over the device. The magnet response is rarely disabled, and if it is disabled, patients are generally aware of it. If you have any questions concerning the use of magnets or suspending device therapy for St. Jude Medical ICD products, please feel free to contact Technical Services at 800-722-3774.

 

[BLADEMDA]

http://www.medscape.com/viewarticle/749751_6

 

[BLADEMDA]

 

[Chloroform4Life]

Here's Boston Scientific's statement on magnet use for their AICD:
https://www.bostonscientific.com/co...sh/ACL_Magnet_to_Inhibit_Therapy_20130416.pdf

So it looks like between the three major makers of AICDs (medtronic, boston scientific, and st jude), magnet pretty much do the same thing (suspend tachy therapy and no effect on brady therapy). Seems reasonable to place magnet for procedures above umbilicus that needs monopolar cautery.

Do you always have device interrogated in PACU after using magnet?

What do you think about lithotripsy?

 

[BLADEMDA]

Here's Boston Scientific's statement on magnet use for their AICD:
https://www.bostonscientific.com/co...sh/ACL_Magnet_to_Inhibit_Therapy_20130416.pdf

So it looks like between the three major makers of AICDs (medtronic, boston scientific, and st jude), magnet pretty much do the same thing (suspend tachy therapy and no effect on brady therapy). Seems reasonable to place magnet for procedures above umbilicus that needs monopolar cautery.

Do you always have device interrogated in PACU after using magnet?

What do you think about lithotripsy?

If the patient has an AICD and is pacemaker dependent you are "rolling the dice" by just placing a magnet for surgeries above the umbilicus where Monopolar cautery is used.
The magnet will suspend the Defibrillator portion but leave the Pacemaker portion "exposed" to the EMI from the cautery. This means the pacemaker may not work at all during long bursts of electrocautery leading to the patient's underlying rhythm. If the patient has no underlying rhythm he/she could arrest on the OR table.

I've seen all this firsthand so take it seriously and it is bad practice IMHO. Pacemaker dependent patients with an AICD/Pacemaker need to have the device reprogrammed preoperatively. If the patient is NOT pacemaker dependent or you are satisfied with the baseline/underlying rhythm then all you need is a magnet (provided the AICD has not had this feature turned off for St Jude and Boston Scientific devices).

 

[sethco]

Biotroniks are junk. IMHO, be on high alert when you see a Biotronik device. Highest quality CIEDs are Medtronic and St jude.

No kidding. In my area, the two most common devices are St Jude and Medtronic, with Boston Scientific coming in a distant third. This was the first time I have taken care of a patient with a Biotronik device

 

[Ignatius J]

It's rare that anything happens except the patient's device will lose battery strength leading to premature replacement.

It's good to know. I'm embarrassed to say that I didn't have a good idea.

 

[Impromptu]

I had an ESWL affect a women's pacemaker function in residency. That was when I learned all about synchronizing the ESWL machine with its own ECG leads in those cases.

 

[deleted162650]

I had an ESWL affect a women's pacemaker function in residency. That was when I learned all about synchronizing the ESWL machine with its own ECG leads in those cases.

Didn't know those machines had that capability. Thanks for that tidbit. Can't wait to do my first cardiac gated ESWL.

 

[Robotic Wis-Hipple]

It honestly amazes me that CT surgeons book cases in patients with CIED's and don't arrange for the rep to be there. Obviously it's still on us to manage it, set the asynchronous rate we want, and generally have an understanding of these devices as emergency cases/add-ons will happen, but for scheduled cases it shocks me. It's like ortho showing up to put a prosthesis in without a rep, or a surgeon booking a case with expected significant blood loss not getting any blood work, cross, etc. Its just strange to me that these things are our job.

 

[Ignatius J]

It honestly amazes me that CT surgeons book cases in patients with CIED's and don't arrange for the rep to be there. Obviously it's still on us to manage it, set the asynchronous rate we want, and generally have an understanding of these devices as emergency cases/add-ons will happen, but for scheduled cases it shocks me. It's like ortho showing up to put a prosthesis in without a rep, or a surgeon booking a case with expected significant blood loss not getting any blood work, cross, etc. Its just strange to me that these things are our job.

Man, I want to work with your surgeons. ;-)

"Yes, I know you never lose blood but it's a 9cm renal mass. I want a type and screen."

"Yes, I know the screen has been sent but he has a history of blood transfusions and it would take 6 hours to get antibody-free blood."

 

[deleted171991]

Man, I want to work with your surgeons. ;-)

"Yes, I know you never lose blood but it's a 9cm renal mass. I want a type and screen."

"Yes, I know the screen has been sent but he has a history of blood transfusions and it would take 6 hours to get antibody-free blood."

"Great. See you in 6 hours."

 

[sethco]

It honestly amazes me that CT surgeons book cases in patients with CIED's and don't arrange for the rep to be there. Obviously it's still on us to manage it, set the asynchronous rate we want, and generally have an understanding of these devices as emergency cases/add-ons will happen, but for scheduled cases it shocks me. It's like ortho showing up to put a prosthesis in without a rep, or a surgeon booking a case with expected significant blood loss not getting any blood work, cross, etc. Its just strange to me that these things are our job.

In Academic practice, this never came up. I presume because the CVTS resident/fellow arranged well in advance for the rep to come in and disable the anti tachycardia function and/or reprogram the PPM. In private practice, they depend on a PA/NP for preop evaluation and arrangements. Difference being that the CVTS resident would be ripped a new one of they forgot to do this. In private practice, this seems to be a regular occurrence (at least once a month) without any consequence. I learned to just roll with it

 

[deleted171991]

In Academic practice, this never came up. I presume because the CVTS resident/fellow arranged well in advance for the rep to come in and disable the anti tachycardia function and/or reprogram the PPM. In private practice, they depend on a PA/NP for preop evaluation and arrangements. Difference being that the CVTS resident would be ripped a new one of they forgot to do this. In private practice, this seems to be a regular occurrence (at least once a month) without any consequence. I learned to just roll with it

You guys need to cancel one of these cases (or postpone it till the rep arrives). Then they will never forget again.

 

[sethco]

You guys need to cancel one of these cases (or postpone it till the rep arrives). Then they will never forget again.

That would probably be pretty detrimental to my partner-track position