Presentation on theme: "26 companies have produced nearly 2000 models of pacemakers"— Presentation transcript:
1 “Just Put a Magnet On It” An Update on Cardiac Implantable Electronic Devices 26 companies have produced nearly 2000 models of pacemakers. (source: Rozner- pacemaker misinformation)Carolyn Boyle, RN, BSN, SRNAGoldfarb School of Nursing at Barnes-Jewish College
2 ObjectivesReview the perioperative implications of Cardiac Implantable Electronic DevicesDiscuss the risks of Electromagnetic Interference (EMI)Examine recommendations for preoperative assessment and preparation, intraoperative management, and postoperative recovery for patients with CIED’s
3 Outline Case Study CIED Review Magnet Mechanism Practice RecommendationsThe Future of CIED’sConclusions
4 Case Study 65 y.o. male with a hx of SCC of the head and neck Presents with flap necrosis, osteonecrosis, orocutaneous fistula formation, & a complicated open wounds/p mandibulectomy, tracheostomy, bil neck dissection, split thickness skin grafting, and G tube placement ~ 8 mos prior.~2 mos prior, pt had flap and trach revisionpresenting for removal of hardware with radial and scapular flap reconstructionPMH: SCC of head and neck, HTN, CHF (EF 30-40%), AFlutter, DM, COPD, Cardiac ArrestTorsades arrest following cardioversion in 2012, warranting AICD placement
5 Case Study con’t.AICD last interrogated preoperatively 2 months prior with recommendations for magnet placement.Uneventful induction of anesthesia, HOB turned 180 degrees, additional PIV’s and arterial line placed. Magnet placed over device and secured with 2 in silk tape.
6 Case Study con’t.Approximately 10 min after incision, surgeon using Bovie electrocautery while exposing the mandiblePatient’s AICD firedNo hemodynamic compromiseNo arrhythmiasWhat happened?In order to explore why this patient’s device fired inappropriately, let’s review CIED’s and perioperative recommendations for their management.Bovie - monopolar
7 Pacemakers In 2001, standardized programming codes were developed: Can be single chamber, dual chamber (A-V), or multi-chamber (bi-V)The leads can be either monopolar or bipolarBipolar is most common today – reduces the risk of electromagnetic interference (EMI)In 2001, standardized programming codes were developed:PACINGSENSINGRESPONSERATE MODULATIONMULTISITE PACINGA = AtriumI = InhibitedR = Rate-modulatingV = VentricleT = TriggeredO = noneD = Dual (A&V)D = Dual (I and/or T)O = NoneBipolar leads have the anode and cathode in the tip of the lead, only centimeters apart, whereas monopolar leads have the cathode in the tip and the device or pulse generator functions as the anode.The reduced distance between the two in the bipolar leads reduces the likelihood of EMI.Standardized programming codes developed by the north american society of pacing and electrophysiology and the british pacing and electrophysiology group in 2001Rate Modulation: allows the pacemaker to increase the paced heart rate in response to certain physiologic situations such as exercise. This can be sensed using different technologies including an accelerometer, thoracic bioimpedance, or even minute ventilation.Multisite Pacing or Cardiac Resynchronization Therapy: mostly used to notate Bi-ventricular pacing. This optimizes the timing of LV and RV systole in patients with severe HF (currently indicated NYHA class 3 or 4, and for LVEF<35%). CRT can improve cardiac output, hemodynamics, HF symptoms, and QOL.
8 Internal Cardioverter Defibrillators (ICD) Detect & treat ventricular arrhythmiasToday, incorporate pacemakers in case defibrillation results in bradycardia or asystoleCan be single chamber (RV lead only), dual chamber (A&V leads), or triple chamber (atrial, RV, LV leads).Pre-programmed ‘zones’ based on heart rates and chamber of origin.Based on rate, the device can initiate anti-tachycardia pacing or deliver a defibrillatory shockProgrammed zones - allows the device to differentiate ventricular arrhythmias from SVT
9 Potential Perioperative Problem: Electromagnetic Interference (EMI) Classic Causes:Surgical electrocauteryNerve stimulatorEvoked potential monitoringRadiofrequency AblationPotential Causes:FasciculationsShiveringLarge tidal volumesLithotripsyPacemaker:Inhibition of pacing due to oversensingBrief exposure generally not a problemProlonged exposure can lead to conversion to asynchronous pacing modeDefibrillator:inappropriate defibrillationEMI is the most common problem in the perioperative period for patients with devices.EMI: Radiofrequency waves interfering with proper device function
10 Magnet Mechanism: The Reed Switch A reed switch consists of two metal strips made of magnetic material in a glass capsule.The strips are open and are not in contact.Application of a magnet causes the strips to come in contact (closed) which triggers the pulse generator to switch to perform programmed functions such as asynchronous pacing or the suspension of anti-tachycardia therapies in ICD’s.This mechanism can be effected by the body habitus of the patient (some manufacturers recommend 2 magnets for super morbidly obese patients), manufacturer, programmed settings, & battery life.Sometimes the reed switch can malfunction by staying in the closed or open position regardless of magnet presence. This is known as a sticky reed switch. Malfunction can lead to anti-tachycardia therapy failure and accelerated battery depletion.As an example of this - Guidant has had problems with this mechanism in a number of ICD’s used in patients with severe cardiomyopathies and they recommended that magnet function be permanently disabled by programmingSource: Sony et al 2011***Magnet effect on CIED is extremely variable depending on thedevice, body habitus, manufacturer, programmed settings,and battery life.
11 Magnet + PACEMAKERUsually, a magnet will convert a pacemaker to asynchronous modeDevice response to magnet can be programmedRate depends on the manufacturer and the battery lifeAsynchronous pacing mode depends on prior settingsDDD DOO VVI VOO AAI AOOCaution: Asynchronous rate may not always meet the physiologic demands of the patientUpon removal, device should revert to originally programmed pacing modeIe- Decreased SVR and hypovolemia may require increased HR
12 Source: Sony et al 2011 BOL – beginning of life ERI – elective replacement intervalEOL – end of lifeSource: Sony et al 2011
13 Magnet + DEFIBRILLATOR Usually, a magnet will prevent antitachycardic pacing and defibrillationIn order to prevent oversensing of EMIModern AICD’s are also pacemakers – a magnet will not have any effect on the pacemaker function!!For patients with AICD’s who are pacemaker dependent preoperative interrogation and reprogramming is recommended
14 -magnet application will have NO effect on pacing. -Boston Scientific and St. Jude devices can be programmed to ignore the magnet!-some (but not all) will may audible noises to indicate that a magnet has been successfully placed-most return to baseline upon magnet reapplication-as always, when in doubt - interrogateSource: Sony et al 2011
16 Focused Pre-Operative Evaluation Presence of deviceH&P, medical record review, CXR, EKG, physical examType of deviceManufacturer ID card, CXR, supplemental records, consult cardiology, year placedDependency on pacemaker functionVerbal history of syncope or bradycardia requiring CIED placement, AV node ablation, 100% paced on EKGDevice functionBest way: comprehensive evaluation (interrogation)At minimum: evaluation of EKG or rhythm strip, discussion with patienthas aicd fired? syncope? cardiology follow up? When was it placed?On average – PM 5-8 yearsAICD 3-6 years
17 CXR InterpretationFemale patient with single lead ventricular pacemaker – tip in the apex of the RV-likely valve repl too – sternal wires visible
18 CXR InterpretationFemale patient with single lead atrial pacemaker (tip in right atrial appendage)
19 CXR InterpretationFemale with two lead pacemaker with leads in RA and RV
20 CXR Interpretation Male with Bi-V pacemaker. White arrow is RA lead. Black arrow is RV lead.While chevron is LV lead in the posterior coronary vein at the LV.
21 CXR Interpretation Patient with ICD. Note the thickened coil representing the defibrillator lead in the RV.
22 Preparation is Everything! Likelihood of Electromagnetic Interference (EMI)Need for preoperative CIED reprogrammingAsynchronous pacingSuspension anti-tachyarrhythmia functionsSuggest the use of Bipolar/ Harmonic electrocauteryAssure presence of external pacing/ defibrillation capabilities before, during, and after the procedureEvaluating the possible effect of anesthetic technique on CIED functionConsider positioning of the patientSpecific anesthetic techniques are unlikely to alter CIED function BUT anesthesia-induced changes (such as HR, BP, rhythm, or ischemia) can lead to unexpected device function.Positioning.Bovie is monopolar
23 EMI above umbilicus? NO YES Pacemaker ICD From: Neelankavil et alEMI above umbilicus?NOYESPacemakerICDNo reprogramming or magnet necessary. Have magnet available.Deactivate ICD – magnet/ reprogramDependent?Yes-Magnet/ reprogram to asynchNo-Consider reprogram/ magnet if source is <15 cm from generator. Have magnet avail.PacemakerDependent?No-No reprogram necessaryYes-Reprogram to asynch.
24 Intra-operative Management If a magnet is placed or the device is reprogrammed, external defibrillation should be immediately available!Place pads as far away from generator as possibleA-P placement is preferred
25 Intraoperative Management Monitor patient appropriately, monitor function of device, and monitor for signs of EMIAssure the cautery grounding pad is positioned so that the current pathway doesn’t cross through or near the deviceThis may mean that sites other than the thigh should be usedSurgeon should avoid cautery near the deviceShort, intermittent bursts of cautery at the lowest possible energy level is idealRisk of EMI is much greater with monopolar than bipolar cauteryASA gives the example of placing the grounding pad on the contralateral shoulder for a head and neck case!
26 Algorithm for Emergent Cardioversion or Defibrillation Surgeon terminates all sources of EMIMagnet placed preopRemove Magnet!Observe for appropriate CIED responsePrepare for external defib or cardioversionDevice reprogrammed preopRe-enable therapies if programmer immediately availableThis algorithm has been adapted from ASA practice advisory – for a patient with ICD facing VTACh in the clinical setting
27 Post-Operative Care Continuous monitoring Pacing & defibrillation availableRegardless of the anesthetic approach to the CIED, electrocautery within 6 inches of the device can damage to the internal circuitry and post-operative interrogation is recommendedIf there is any question, device should be interrogated to assess function
28 Case Study ConclusionElectrocautery removed from the field, device representative called to the roomInterrogated device, confirmed defibrillationUnsure why magnet failedManual reprogramming of defibrillatorSurgery proceeded without further incidentDevice interrogated postoperatively and returned to preoperative settings
33 ReferencesAmerican Society of Anesthesiologists Committee on Standards and Practice Parameters. (2011). Practice advisory for the perioperative management of patients with cardiac implantable electronic devices: Pacemakers and implantable cardioverter-defibrillators. Anesthesiology, 114, doi: /ALN.0b013e3181fbe7f6 Neelankavil, J. P., Thompson, A., Mahajan, A. (2013). Managing cardiovascular implantable electronic devices (CIED’s) during perioperative care. APSF Newsletter, 28, Jacob, S., Panaich, S. S., Maheshwari, R., Haddad, J. W., Padanilam, B. J., John, S. K. (2011). Clinical applications of magnets on cardiac rhythm management devices. Europace, 13, doi: /europace/eur137 Lanzman, R. S., Winter, J., Blondin, D., Furst, G., Scherer, A., Miese, F. R., Abbara, S., Kropil, P. (2011). Where does it lead? Imaging features of cardiovascular implantable electronic devices on chest radiograph and CT. Korean J Radiol, 12 (5), doi: /kjr Schulman, P. M., Rozner, M. A. (2013). Use caution when applying magnets to pacemakers or defibrillators during surgery. Anesthesia & Analgesia, 117, doi: /ANE.0b013e a1 Rooke, G. A., Bowdle, T. A. (2013). Perioperative management of pacemakers and implantable cardioverter defibrillators: It’s not just about the magnet. Anesthesia & Analgesia, 117, doi: /ANE.0b013e f3 Rozner, M. (2004). Pacemaker misinformation in the perioperative period: Programming around the problem. Anesthesia & Analgesia, 99, doi: /01.ANE D7