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Pacemaker and ICD Basics for all ProvidersGLENDA S. DELL MSN, RN ACNS-BC

TNP CONFERENCE

SEPTEMBER 9, 2016

Objectives

u Partic ipants will identify indications for pacemakers , defibrillators , and cardiac resynchronization devices.

u Partic ipants will identify complications in newly implanted and chronic devices.

u Partic ipants will identify current remote monitoring capabilities in device follow up.

u Partic ipants will identify special cons iderations and end of life cons iderations of device patients .

u Partic ipants will identify indications for the wearable defibrillator.

Devices Pacemakers

u Between 1993 and 2009, 2.9 million patients received permanent pacemakers in the United States. Overall use increased by 55.6%.

u Dual chamber pacemaker use increased from 62% to 82% .

u Single-chamber ventricular pacemaker use fell from 36% to 14% .

Pacemakers

u The purpose of permanent pacing is to electrically stimulate myocardial contraction, and to restore and maintain an appropriate heart rate or ventricular synchrony when a chronic conduction or impulse formation disturbance exists in the cardiac conduction system (Offutt, 2011).

Pacemakers

u Class I indications for pacemaker implantation in sinus node dysfunction:

u Sinus node dysfunction with symptomatic bradycardiau Symptomatic chronotropic incompetence with sinus

node dysfunction.

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Pacemakers Pacemakers

u Class I indications for pacemaker implantation:u 3rd AVBu 2nd AVBu Atrial fib with a slow ventricular response.u Hypersensitive carotid syndrome.u Drug induced conduction abnormalities.

Pacemakers

u Does my patient need a pacemaker?u Patient history: Primary reason for visit.u Medication history: specifically cardiovascular medications, also

tricyclic antidepressants, lithium, and phenothiazines (antipsychotics).

u Medical history: specifically cardiovascular disease.

Pacemakers

u Diagnostic testing:u 12 lead EKGu Holter Monitor u Event Monitoru Loop recorder

Pacemakers Pacemakers

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Pacemakers ICDs

u The purpose of the implantable cardioverter-defibrillator(ICD) is a device that is used to prevent sudden cardiac death from malignant ventricular dysrhythmias. The ICD continuously monitors a patient’s rhythm and attempts to convert ventricular tachycardia or ventricular fibrillation via antitachycardia pacing, cardioversion, defibrillation, or some combination of these. The ICD has the capability for backup bradycardia pacing (Offutt & Josephson-Keeven, 2011).

ICDs

u Class I Indications for ICD’s:u Patients with LVEF <35% and the presence of prior MI.u Patients with LV dysfunction with a prior MI with LVEF

<30% and are NYHA class I.u Patients with Nonsustained VT due to prior MI who have

LVEF <40% and inducible VF or VT during an EP study.

ICDs

u Class I Indications for ICD’s:u Survivors of cardiac arrest as a result of VF or VT. u Patients with structural heart disease and sustained VT. u Patients with syncope of undetermined origin with

hemodynamically significant VT or VF at EP study.u Patients with non-ischemic dilated cardiomyopathy with

the left ventricular ejection fraction < or equal to 35% and are NYHA functional class II or III.

ICDs

Other Considerations (class IIa and IIb) :

u Persons awaiting heart transplantation outs ide the hospital.

u Hypertrophic cardiomyopathy with one or more major risk factors for sudden cardiac death.

u Long QT syndrome.

u Non-ischemic heart disease with an LVEF <35% and NYHA class I.

ICDs

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ICDs Cardiac Resynchronization

u Class I Indications:u LVEF<35%, in sinus rhythm, has a LBBB with a QRS duration of greater

than 150ms, and NYHA class II, III or a ambulatory IV.u Class IIa Indications:u CRT can be useful in pts with LVEF<35%, in sinus rhythm, has a LBBB

with a QRS duration of 120-149ms and NYHA class II, III or a ambulatory IV.

u In patients with atrial fib with LVEF<35%, pt. requires Ventricular pacing and meets other CRT criteria and has AV nodal ablation or pharmalogical rate control that will allow near 100% ventricular pacing with CRT.

ICDs Pacemakers and ICDs

Complications from implant:u Infection

u Bleeding

u Pneumothorax

u Lead dis lodgement

u Lead perforation

u Venous Thrombos is and Superior Vena Cava Syndrome(SVCS)

Long term complications Chronic device:u Generator failure(rare)

u Lead failure

u Extra cardiac stimulation( can occur in acute or chronic phase)

u Twiddler’s Syndrome

u Skin eros ion

u Late infection

Pacemakers and ICDs Pacemakers and ICDs

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Pacemakers and ICDs Pacemakers and ICDs

Symptoms patient may experience with a pacemaker malfunction:u Dizziness or lightheaded episodesu Syncopeu Weaknessu Easy fatigabilityPatient should be aware of the return of any symptoms they had prior to pacemaker implant.

Pacemakers and ICDs

u Patients with pacemakers and ICDs need regular follow up on their device.

u Ask patient who has a device about their follow up:u Should be checked once/90 days either in person or by

phone

Pacemakers and ICDs

Pacemakers and ICDs

When should I call the pacemaker clinic:u Decreased Heart rate.u Excessive pain, drainage, redness, or swelling.u Fever.u Lightheadedness or feeling faint.u Shortness of breath or fatigue.u Palpitations or continuous fast heart rate.u Hiccups.

Pacemakers and ICDs

Do’s and don'ts:u Household appliances including microwaves are ok to use.u Cell phones are ok.u Anti-theft systems.u Metal detector.

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Pacemakers and ICDs

Do’s and Don’ts:u Welding equipment. u For most patients MRI is contraindicated.u TENS unit.u Radiation. u Surgery with electrocautery.

Pacemakers and ICDs

Pacemakers

u R E A S O N F O R V IS IT :

u

u P A C E MA K E R : MO D E :

u

u IMP L A N T D A T E : IMP L A N T S IT E :

u

u C O N D IT IO N :

u

u P A C IN G IN D IC A T IO N : P L A C E ME N T :

u

u

u

u P P M D E P E N D E N T : T E L E ME T R Y :

u

u C U R R E N T R H Y T H M: IN T R IN S IC R H Y T H M:

u

u P R O G R A MME D S E T T IN G S :

u L O W R A T E :

u U P P E R R A T E :

u A -D E L A Y (S ):(P ):

u S E N S IT IV IT Y R A T E (A ):(V ):

u R E S R E S P O N S E :

u MO D E :

u P U L S E W ID T H (A ):(V ):

u A MP L IT U D E (A ):(V ):

u R E F R A C T O R Y (A ):(V ):

u MA G N E T R A T E :

u

u C A P T U R E T H R E S H O L D S :

u A T R IA L :

u V E N T R IC U L A R :

u

u S E N S IN G T H R E S H O L D S :

u A T R IA L : MV (A P P R O P R IA T E [ ] O V E R [ ]

u U N D E R [ ]) B IP O L A R [ ] U N IP O L A R [ ]

u V E N T : MV (A P P R O P R IA T E [ ] O V E R [ ]

u U N D E R [ ]) B IP O L A R [ ] U N IP O L A R [ ]

u

u L E A D IMP E D A N C E :

u A T R IA L

u V E N T

u

u E R I R E A C H E D :

u D Y S R H Y T H MIA S N O T E D :

u B A T T E R Y D E P L E T IO N :

u

u IMP R E S S IO N S :

Pacemakers

u What do the findings mean:u ERI- Elective replacement indicatoru EOL- End of Lifeu Mode Switch Episodes- usually indicate atrial fib.u Ventricular High Rate Episodes- can indicate NSVT.

ICDs

u REASON FOR VISIT:

u

u ICD MANUFACTURER/MODEL:

u

u DATE OF IMPLANT: IMPLANT SITE:

u

u ELECTIVE REPLACEMENT INDICATOR:

u

u BATTERY VOLTAGE:

u

u PACING LEAD OHMS: ATRIAL : VENTRICULAR: HV:

u

u R WAVE AMPL ITUDE: P WAVE AMPLITUDE:

u

u PACING THRESHOLD: ATRIAL: VENTRICULAR:

u

u SENSI NG PACI NG MO DE:

u PACI NG RATE: LRL: URL: RATE RESPO NSE:

u

u AMPLI TUDE: ATRI AL: VENTRI CULAR:

u

u PULSE W I DTH: ATRI AL: VENTRI CULAR:

u

u SENSI TI VI TY: ATRI AL: VENTRI CULAR:

u

u FI B EVENTS: FAST V TACH: V TACH: NST/SVT:

u

u TO TAL SHO CKS:

u

u ABO RTED THERAPY:

u

u CAPACI TO R MAI NT. CHARGE: SECO NDS:

u

u SYMPTO MS ASSO CI ATED W I TH THERAPY:

u

u PRO GRAMMED CHANGES:

u PHYSI CI AN CO MMENTS:

ICDs

u What should patients do when they receive a shock?u If patient receives one shock and does not pass out he should

call the device clinic.u If patient receives two or more shocks in the same day he

should go the nearest ER for evaluation.

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ICDs

u What does the magnet do over the ICD?

u

u Will Not Detectu Can Not Deliver Therapyu No effect on pacemaker function

ICDs

u Special Considerations:u Emotional response to having an ICD.u Anxiety and fear increase after patient experiences a shock. u Feel sense of loss of control.

ICDs

u End of Life Considerations:u Deactivation of the ICD.u Discussion should be had with patient/POA prior to deactivation.u Must have a DNR order and a separate order to deactivate ICD.u Encourage patients to express their wishes for device management

and deactivation as part of their advanced directive.

Wearable ICDs

Wearable ICD Pacemakers and ICDs

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Helpful Websites:

u www.medtronicacademy.com

u www.bostonscientific.com

u www.s jm.com

References:

u Boston Sci ent i f i c. ( 2013) . Cardi ac rhythm resource center. Retri eved f rom

http: //w ww .bostonsci ent i f i c. com

u Enes El vi n Gul and Mehmet Kayrak ( 2011) . Common Pacemaker Probl ems: Lead and Pocket

Compl i cat i ons, Modern Pacemakers - Present and Future, Prof . M i thi l esh R Das ( Ed. ),

ISBN: 978- 953- 307- 214- 2, I nTech, Avai l abl e f rom: http: //w ww .i ntechopen. com/books/modern-

pacemakers- present - and- future/common pacemaker- probl ems- l ead- and- pocket - compl i cat i ons

u Fuertes, B. , Toquero, J . , Arroyo- Espi l guero, R. , & Lozano, I . F. ( 2003) . Pacemaker l ead

displ acment : mechani sms and management . I ndi an Paci ng and El ectrophysi ol ogy Journal ,

( Fuertes, Toquero, Arroyo- Espi l guero & Lozano, 2003) 3( 4) , 231- 238.

u Greenspon AJ , Patel J D, Lau E, et al . (2012) . Trends i n Permanent Pacemaker I mpl antati on i n the

Uni ted States from 1993 to 2009: I ncreasi ng Compl exi ty of Pat i ents and Procedures. Journal

of Ameri can Col lege of Cardi ol ogy. 2012; 60( 16) : 1540- 1545. doi : 10. 1016/j . j acc. 2012. 07. 017.

u Heal ey, J . S. , Connol l y, S. J. , Gol d, M. R. , Israel , C. W ., Van Gel der, I . C. , Capucci , A. , Lau, C.

P. , & Hohnl oser, S. H. ( 2012) . Subcl i ni cal at rial f i bril l ati on and the ri sk of st roke. The New

Engl and Journal of Medi ci ne, 366, 12012- 9. doi : DO I : 10. 1056/NEJ Moa1105575

u Mal am, D. , Karl sson, J . E. , & Fri dl und, B. ( 2007) . Ef fects of a sel f -care program on the heal th-

rel ated qual ity of l i fe of pacemaker pat i ents: a nursi ng intervent i on study. Canadi an Journal of

Cardi ovascul ar Nursi ng, 17( 1) , 15- 26.

u Medtroni c ( 2012) . Corepace. Retri eved f rom http: //w w w. medtroni cconnect . com

References:

u Olshansky , B., & Hayes, D. L . (2013). Patient information: Pacemakers (beyond the basic s).

Retrieved from http://www.uptodate.com

u St. Jude Medical. (2012). Clinical disc overies for healthc are professionals. Retrieved from

http://www.c linic al.s jm.com

u Tracy , C. M., Eps tein, A. E ., Darbar, D., DiMarco, J. P ., Dunbar, S . B., Es tes , M., Ferguson, T.

B., & Varosy , P. D. (2012). Acc f/aha/hrs focused update of the 2008 guidelines for dev ice-

based therapy of cardiac rhy thm abnormalities. Journal of the American College of

Cardiology , 60(14), 1297-1313. doi: doi:10.1016/j.jacc .2012.07.009