Cardiac Implantable Devices

Nursing Care:

The Basics and Beyond

Welcome!

Terri Rhodes, RN, BSNClinical Level III, CEP Lab Nurse

Laura Hess, RN, BSNClinical Level II, CEP Lab Nurse

Please feel free to ask questions during the presentation!

Objectives:Examine device terminologyExamine the components, functions and

indications for a pacemakerInventory the components, indications and

functions of an internal cardiac defibrillator (ICD)Compare the pacing modes using NBG pacing

code system Assess patient needs preoperativelyManage patient postoperativelyAnalyze rhythm strips for appropriate pacemaker

and ICD functioning

Outline

1. Welcome and general information2. Pacemakers3. ICD’s4. NBG codes5. Biventricular Pacing6. Nursing Considerations7. Pacemaker Practice Strips

Normal Conduction System

A Brief History of Implantable Devices

1958 - First human implantDr. Senning in Stockholm, only lasted 3 hours

1960- First clinically successful human implant Dr’s Chardack and Gage in the USWilliam Greatbatch, engineer

1965- First VVI implanted1972- Partially programmable1977-Multiprogrammable1981- Dual chamber multi-programmable

Along Came ICD’s…1980 - First human implantThoracotomy

Epicardial patch & lead Large device placed in abdomen Not programmable; i.e. only one setting

Second generation ICD Transvenous electrode Bradycardia & anti-tachycardia pacing

Fifth generation Dual-chamber rate responsive pacing Improved recognition of SVT

The Next Generation Remote interrogation CHF Management S-ICD- subcutaneous ICD

General “Device” Terms to Understand

SenseFireCapture

Sense

Sense: the ability of the device to recognize the presence or absence of an innate “p” wave or “qrs” complex

Fire

Fire: the device has sensed a missed “p” wave or “qrs” complex, and has sent energy down the pacing wire to the tissue

Capture

Capture: the energy has contracted the myocardial tissue, and resulted in a “p” wave or “qrs” complex on skin leads

Device Terms Continued… Failure to Capture:

A spike is noted on strip, but is not followed by appropriate “p” or “qrs” wave form

Failure to Sense Spike (energy) is missing during absence of “p” or “qrs” Spike noted at inappropriate times

R on T Occurs when device fails to sense, and delivers energy during

vulnerable T wave - or – if programmed at VOO/AOO, the pacemaker delivers the energy in spite of intrinsic activity and paces on the t-wave.

Failure to Fire Device does not send energy (pacer spike) when indicated

***If you notice any of these, check your patient, check pulse and notify physician***

What Do You Need To Have a Paced Beat?

Atrial Paced Beat: “a” pacing spikeP wave immediately following pacer spike

Ventricular Paced Beat:“v” pacing spike QRS immediately follows pacing spike

Examples of Paced “a”,Paced “v”, and Both

Pacemakers

What is a pacemaker?

A internal device that regulates electrical impulses through the heart. Sense FireCapture

Single Chamber, Dual Chamber and Bi-Ventricular

Pacemaker Components

Pulse generator- battery which provides the energy. Controls the rate, output, and sensitivity. The “Can”

Leads- carries the impulse to the heart tissueAtrial Right VentricleLeft Ventricle

Coronary Sinus

Indications for pacemakersSymptomatic 2nd degree, Mobitz Type II heart

blockComplete heart block (3rd degree) AsystoleSymptomatic bradycardiaSinus node dysfunctionCarotid sinus syndrome and hypersensitivity

An exaggerated response to carotid sinus baroreceptor stimulation. Sometimes even mild stimulation in the neck region causes a marked decrease in heart rate, blood pressure, and causes syncope.

Other Indications

Hypertrophic Obstructive Cardiomyopathy (HOCM)S/P Alcohol Septal Ablation

Congestive heart failure (CHF) Biventricular pacing

Magnet Placement for a Pacemaker

Temporarily changes the mode of pacing to asynchronous (VOO, DOO) while magnet is in place.

Paces regardless of rhythmThis is programmable feature of the

device; NOT ONE SIZE FITS ALL

Break???

Intracardiac Cardioverter Defibrillatorsor

ICD’s

What is an ICD?

An internal device that can regulate electrical impulses through the heart, but its main function is to detect and terminate tachy arrhythmias. DefibrillationOverride pacingCardioversion Pacemaker Functions (Single/Dual/BiV)

Components of an ICD

Pulse generator- battery which provides the energy. Detects tachy arrhythmias and delivers defibrillation energy when indicated. Controls the rate, output, and sensitivity of the pacemaker function. The “Can”

Leads- carries the impulse to the heart tissueRight Ventricle

Endo Coil – High output leadAtrium

Pacemaker leadLeft Ventricle

Placed via the Coronary Sinus when placed in EP lab, and epicardial when placed in OR

Unipolar ICD

Indications for ICDs

Secondary prevention (already had event)Sudden Cardiac Death; NSVT, Sustained VT, V-

fib arrestInducible VT (EP testing)Primary prevention (trying to treat FIRST event)Cardiomyopathy (SCD-HeFT)At risk for sudden cardiac death

Unknown etiologyLong QTBrugada Syndrome (Na channel abnormality resulting in

RBBB with J point elevation and concave ST elevation)Cardiac Sarcoid

And the Latest…S-ICD

The S-ICD System is intended to provide defibrillation therapy for the treatment of life-threatening ventricular tachyarrhythmias in patients who do not have:

*symptomatic bradycardia

*incessant VT

*spontaneous, frequently recurring VT that is reliably terminated with anti-tachycardia pacing

Which one do you want?Traditional ICD S-ICD

*Provides effective defibrillation *Provides effective defib for for ventricular arrhythmias ventricular arrhythmias*Provides brady pacing *No risk of vascular injury*Provides ATP pacing *Low risk of systemic injury*Provides atrial diagnostics *Preserves venous access*Familiarity of implant technique *Avoids risk of endovascular lead extraction

Magnet Placement for an ICD Suspends tachycardia detection while

the magnet is in place

Pacing parameters remain unchanged This is a programmable feature of the

ICD, and may be different

Caution!Place magnet on device ONLY under

guidance or supervision from a physician or Electrophysiology Department nurse.

Examples of when placing magnet is appropriate: ICD “ shocking” at inappropriate timesDuring OR procedures requiring cautery. Stat

pads must be placed on patient.During a code situation when you want to take

‘control of the shocking’

Special Considerations for Pt’s with ICD’s If ICD discharges?

1. Check your pt: Think BLS/ACLS! ABC’s, is pt. responsive, what rhythm are they in?Take appropriate action if pt. is not stable

2. If pt. is stable notify EP departmentDuring a CODE?

DO NOT place STAT pads directly over device UCH policy: Place external defibrillator pads 4-6 inches away

from the device laterally if possible. Pt. is going for another OR procedure

Notify Anesthesia that pt. has device, tell them the company and they will notify the EP department

Break?

NBG CodesGeneric code created for NASPE and

BPEG. (NASPE is the North American Society of Pacing and Electrophysiology.BPEG is the British Pacing and Electrophysiology Group.)

Pacemaker programming codes that identifies how the pacemaker is programmed to function.

NBG Codes: Programming the pacemaker

I- What chamber do you want to pace?II- What chamber do you want to sense?III-What do you want to do with the

sensed information? Inhibit pacing or trigger pacing?Tracking the Atrial activity

IV-Do you want to increase the rate with the patient’s activity?

NBG Code ReviewNBG Code Review

IChamber

Paced

IIChamber

Sensed

IIIResponseto Sensing

IVProgrammableFunctions/Rate

Modulation

V: Ventricle V: Ventricle T: Triggered P: Simpleprogrammable

A: Atrium A: Atrium I: Inhibited M: Multi-programmable

D: Dual (A+V) D: Dual (A+V) D: Dual (T+I) C: Communicating

O: None O: None O: None R: Rate modulating

S: Single (A or V)

S: Single (A or V)

O: None

Position

Category

LettersUsed

Manufac-turer’sDesignationOnly

I II III

Chamber(s)Paced

Chamber(s)Sensed

Responseto Sensing

Programmability,rate modulation

O-None

R-Rate modulation

O-None

A-Atrium

V-Ventricle

D-Dual(A+V)

S- Single(A or V)

S- Single(A or V)

O-None

A-Atrium

V-Ventricle

D-Dual(A+V)

O-None

T-Triggered

I-Inhibited

D-Dual(T+I)

IV

The NBG pacing code

Position

Category

LettersUsed

Manufac-turer’sDesignationOnly

I II III

Chamber(s)Paced

Chamber(s)Sensed

Responseto Sensing

Programmability,rate modulation

O-None

R-Rate modulation

O-None

A-Atrium

V-Ventricle

D-Dual(A+V)

S- Single(A or V)

S- Single(A or V)

O-None

A-Atrium

V-Ventricle

D-Dual(A+V)

O-None

T-Triggered

I-Inhibited

D-Dual(T+I)

IV

The NBG pacing code

Position

Category

LettersUsed

Manufac-turer’sDesignationOnly

I II III

Chamber(s)Paced

Chamber(s)Sensed

Responseto Sensing

Programmability,rate modulation

O-None

R-Rate modulation

O-None

A-Atrium

V-Ventricle

D-Dual(A+V)

S- Single(A or V)

S- Single(A or V)

O-None

A-Atrium

V-Ventricle

D-Dual(A+V)

O-None

T-Triggered

I-Inhibited

D-Dual(T+I)

IV

The NBG pacing code

Position

Category

LettersUsed

Manufac-turer’sDesignationOnly

I II III

Chamber(s)Paced

Chamber(s)Sensed

Responseto Sensing

Programmability,rate modulation

O-None

R-Rate modulation

O-None

A-Atrium

V-Ventricle

D-Dual(A+V)

S- Single(A or V)

S- Single(A or V)

O-None

A-Atrium

V-Ventricle

D-Dual(A+V)

O-None

T-Triggered

I-Inhibited

D-Dual(T+I)

IV

The NBG pacing code

Single Chamber Pacing

How Do We Use The NBG Language?

Ventricular lead

• Ventricular pacing

• Ventricular asynchronous pacing at lower programmed pacing rate

• Used for: surgical procedures with cautery

*

• No sensing

VOO

I*Ventricular

lead

• Sensed intrinsic QRS inhibits ventricular pacing

• Used if patient is in A-fib, do not want to tract the atrial rate

• Ventricular pacing

• Ventricular sensing

VVI

*Atrial lead• Atrial asynchronous pacing

at lower programmed pacing rate

• Atrial pacing

• No sensing

AOO

*Atrial lead

Indications: Sinus Node Dysfunction

• Atrial pacing

• Atrial sensing

• Intrinsic P wave inhibits atrial pacing

AAI

Dual Chamber Pacing

Tracking Mode:

Both triggers and inhibits pacing

Benefits of Dual Chamber PacingBenefits of Dual Chamber Pacing

Provides AV synchronyProvides AV synchrony

Lower incidence of atrial fibrillation Lower incidence of atrial fibrillation

Lower risk of systemic embolism and Lower risk of systemic embolism and strokestroke

Lower incidence of new congestive heart Lower incidence of new congestive heart failurefailure

Lower mortality and higher survival ratesLower mortality and higher survival rates

*

*Atrial lead

Ventricular Lead

• Pacing in both the atriumand ventricle

• Sensing in both the atrium and ventricle

• Intrinsic P wave and intrinsic QRS can inhibit pacing

• Intrinsic P Wave can “trigger” a paced QRS

• Maintain AV synchronization

I

DDD

DDD pacing

Dual-chamber pacing capable of pacing and sensing in both the atrial and ventricular chambers of the heart

4 distinct patterns can be observed with DDD pacing

DDD pacingSensing in both the atrium and the ventricle (inhibiting in both the atrium and the ventricle)

DDD pacingPacing in the atrium with sensing (inhibition of pacing) in the ventricle

DDD pacingSensing in the atrium (inhibition of atrial pacing) and pacing in the ventricle

Also known as “P wave tracking”

DDD pacingAtrial pacing and ventricular pacing (no inhibition of pacing)

DDD mode

May resemble other modes of pacing

Will strive to maintain AV synchrony with variable atrial rates and AV conduction

Dual Chamber Timing ParametersDual Chamber Timing Parameters

Lower rateLower rate

Upper rate intervalsUpper rate intervals

Lower Rate Interval

APVP

APVP

Lower Rate Lower Rate

The lowest rate the pacemaker will pace The lowest rate the pacemaker will pace the atrium in the absence of intrinsic atrial the atrium in the absence of intrinsic atrial eventsevents

DDD 60 / 120

New Slide

ASVP

ASVP

DDDR 60 / 100 (upper tracking rate) Sinus rate: 100 bpm

Lower Rate Interval {

Upper Tracking Rate Limit

Upper Tracking RateUpper Tracking Rate

The maximum rate the ventricle can be The maximum rate the ventricle can be paced in response to sensed atrial eventspaced in response to sensed atrial events

SAV SAVVA VA

New Slide

Rate responsiveness/ adaptive-rate pacing

The 4th Letter in the NBG Code

Rate responsiveness/adaptive-rate pacing

Rate response attempts to mimic the sinus node by increasing heart rate in response to increasing metabolic demand

Rate responsiveness/adaptive-rate pacing

Sensor(s) detect changes in physiologic needs and increase the

pacing rate accordingly

Rate responsiveness/adaptive-rate pacing

The sensor detects changes by:Sensing motion (crystal or

accelerometer)

Sensing changes in intrathoracic impedance, e.g., minute ventilation

DDDR pacing

Example of Dual-Chamber Rate-Responsive pacing

Biventricular PPM or ICD

A Brief Overview of What It Means To BiV Pace

Biventricular pacing

Three lead system:

Right atrial

Right ventricular

Left ventricular

Biventricular pacing

Cardiac Resynchronization Therapy (CRT)

Patient Indications

Bi-Ventricular ICD

Moderate to severe HF (NYHA Class III/IV) patients

Symptomatic despite optimal, medical therapy

QRS 130 msec

LVEF 35%

Biventricular pacing Also known as cardiac resynchronization

therapy, keeps the right and left ventricles pumping together by sending small electrical impulses to the heart muscle coordinating their contractions.

The heart is able to fill and pump blood more effectively. This along with medical therapy, helps to improve heart failure symptoms.

Improves quality of life in many.

Biventricular pacing

Achieved by: Inhibiting intrinsic ventricular rhythm

Ensure pacing in RV and LV

Short A-V delays to promote pacing in the ventricle

Break?

When Devices Go Bad!!!!

Complications of Device Implantation:

Pocket hematoma Pocket infectionPneumothoraxCardiac perforationCardiac tamponadeVascular damage

Lead dislodgementLead fractureLead infectionInappropriate shocks

Laser Lead Extraction Program

Implemented at UCH in 2008 by Chancey Weaver RN and Dr. Michelle Khoo M.D.

First laser lead extraction in January 2009~30 leads extracted/year

Reasons for a lead extraction: Fractured Leads Infected Lead(s)Non-functional leads/too many leadsRegaining venous access

Unexplained Dents!

Device Erosion

Lead Fracture

Intraprocedure

Extracted Lead

Extracted Generator and Lead

Nursing Considerations

Preoperative ICD Placement

and

Postoperative Care

Preoperative

Left/right arm IV Reinforce patient and family education

EP department performs education prior to and after procedure, any further questions, please call the EP lab

NPO Surgical site Pre-op medications

Antibiotics Blood work (WBC, Platelets, INR, Basic) Anesthesia in the procedure Restrictions after procedure

Postoperative Vital signs

Changes may indicate pericardial effusion or pneumothorax

Type of device and settings ECG interpretation and documentation, as per unit guidelines Activity HOB <30 degrees for the first 4 hours Antibiotics Incision site X-ray within 1 hour of arriving back in room and X-ray in AM as well

**Pt. placed in sling for 24 hours to allow leads to adhere to tissue**

Documentation According to hospital policy:

University of Colorado HospitalCall report to telemetry: Include device manufacturer and

model number, mode (VVI, DDD, etc.), and lower and upper programmed rates (should be given in report).

Place in computerized documentation: Device manufacturer, mode, rate, rate cut off, therapies, and date of implant.

If the device fires, document any therapies of the device including the precipitating dysrhythmia and outcome in your charting. Include ECG strips, if available, documenting the dysrhythmia, the delivery of the therapy via the ICD and the resultant rhythm and the patient response.

Strip Documentation

According to hospital policy, and individual unit guidelines.Minimal information includes “running” a strip

every 12 hours or with a change in rhythmDocumentation: date, time, patient's name,

medical record #, heart rate, PR, QRS, and QT intervals, and rhythm analysis

Wound care S/S of infectionNo submersion under water for 3 weeksNo direct water spray (shower spray) for 1 week

Coughing and deep breathing Activity

All information in Post Op packetNO lifting arm above shoulder for 6 weeks

Follow-up appointment Remote interrogations Electromagnetic interference Identification card

Patient and Family Education

Patients Admitted With a PPM or an ICD

Patients admitted with a PPM/ICD

Ask patient for device information, i.e. registration card

EP does not need to be consulted if a patient is admitted for a non-device related problem and the device appears to be working appropriately.

MRI not recommended (except new Medtronic PPM)

Pre-op/Post-op patients may require device programming changes ICD- tachy therapies off, or may fire during cautery PPM- reprogram to VOO, or may fail to pace

appropriately

Pacemaker Practice Strips

What You Need to Document

Underlying rhythm?Is it “a” paced, “v” paced or both

Is the device doing what it is programmed to do?

Troubleshooting

Failure to:SenseFireCapture

How to interpret a “paced” strip: One method of many…

1. Is intrinsic activity present?2. Are pacing spikes present: “A”, “V”, or both?3. Is 1:1 capture present?4. Is intrinsic activity sensed appropriately?

Over sensing- sensing of an inappropriate singleLeads to underpacing

Under sensing- failure to sense intrinsic cardiac signal

Results in overpacing5. What is the heart rate? 6. What is the programmed pacing rate?

Compliments of Northwestern Memorial Hospital, October 2002

Is This Normal Device Operation?Is This Normal Device Operation?

Is This Normal Device Operation? Is This Normal Device Operation?

What Device Operation is This?What Device Operation is This?

Is This Normal Device Operation?Is This Normal Device Operation?

Is This Normal Device Operation?Is This Normal Device Operation?

What is missing?

Thank YouCardiac Electrophysiology

Dena Keilman, RN Kari Jackson, RN Noelle Hernandez, RN Amanda Lange, RN Heidi Huber, RN Terri Rhodes, RN Dan Sullivan, RN Claire Rutherford, RN Matt Upton, RN Laura Hess, RN Diane Ridgway, RN Ann Czyz. RN

William H. Sauer, MDDuy Nguyen, MDPaul Varosy, MDRyan Aleong, MDJoe Schulller, MDWendy Tzou, MDChristine Tompkins, MDDavid Katz, MDCathy Kenny, ANP

References

Burke M, et al. Safety and Efficacy of a Subcutaneous Implantable-Defibrillator (S-ICD System US IDE Study). Late-Breaking Abstract Session. HRS 2012.