You’ve Come Along Way u Baby: Pacemakers and u

8/9/18

You've Come Along Way

Baby: Pacemakers and ICDs

GLENDA S. DELL MSN, APRN ACNS-BC TNP CONFERENCE SEPTEMBER 8, 2018

Objectives

u Participants will learn the history of pacemakers and ICDs. u Participants will identify MRI compatible pacemakers and ICDs. u Participants will identify indications for wireless pacemakers and ICDs and

implications for care. u Participants will identify indications for HIS bundle pacing.

Disclosures:

u I have nothing to disclose.

Devices

History

Transcutaneous Pacemaker

Portable Pacemaker

History

u October 8th 1958 first implantable pacemaker in Sweden by Senning and Elmvquist.

u Done by thoracotomy and 2 epicardial leads placed. u Device lasts 3 hours. u The recipient Arne Larsson survived until 2001(his cause of death was not

related to his cardiac issues)

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History

u 1970s Nuclear pacemaker were developed. u Pacemaker become non-invasively programmable in the mid 1970s. u Dual chamber devices are developed in the late 1970s. u The 1980s drug eluding steroid leads, rate response pacing developed. u The 1990s micro-processor pacemakers appeared u The 2000's biventricular pacing introduced. u 2015 HIS bundle pacing.

History

First pacemaker

Pacemakers Today

History

u 1980 the first ICD was implanted by Michel Mirowski and his team. u Was considered a treatment of last resort. u Devices were large, performed by open chest surgery.

History

History

Trials Sample size

Design

MADIT [10] 196

MUSTT [11] 704

MADIT II [13] 1232

ICD vs antiarrhythmic drugs as conventional therapy

EP-guided therapy vs placebo

ICD vs optimal pharmacological therapy

Patients

Previous MI, EF 0.35,

Coronary disease,

nsVT, positive findings on EF 0.40, nonsustained

EPS

VT, inducible VT at EPS

Prior MI, EF 0.30

Follow-up (months) Results Risk reduction with ICD

27 54% (P = 0.001)

39 51% (P = 0.001)

20 31% (P = 0.02)

SCD-HeFT [28] 2521

ICD vs optimal pharmacological therapy vs optimal pharmacological therapy + amiodarone

Ischemic and nonischaemic cardiomyopathy, EF 0.35

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23% (P = 0.007)

History

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History

History

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MRI Devices

MRI Devices:

u MRI conditional devices contain a dedicated MRI pathway. u Safety features include: u System integrity checks, Asynchronous pacing, tachy detections disabled,

increased output during the scan, return to preprogrammed state. u Most MR conditional devices use 1.5T scans in "normal operating mode" u If patient has abandoned or epicardial leads MRI is not recommended.

MRI Devices:

u Identify Patient has an MRI compatible device and leads. u Verify patient has had the device at least 6 weeks. u Scheduling will require coordination between radiology and cardiology. u Device may cause image artifact.

MRI Devices:

u Once scheduled: u Device clinic staff should be present to test and reprogram device prior to

MRI. u EKG and Pulse Oximetry monitoring should be done throughout the scan. u Patient's device should be checked post MRI. u ILR(implantable loop recorder) should be interrogated pre-MRI.

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MRI Devices:

MRI: Devices

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MRI Devices:

u Contact information: u Medtronic: 1-800-551-5544 u Boston Scientific: 1-800-227-3422 u ST Jude/Abbott: 1-800-722-3774 u Biotronik: 1-800-547-0394

MRI Devices: Medtronic

MRI Devices: Boston Scientific

MRI: St Jude/Abbott

Pacemakers

Assurity 1272 Assurity 2272

Confirm implantable Cardiac Monitor.

1.5 T MRI image scans

ICDs/CRT-D

Ellipse VR Ellipse DR Fortify Assura VR Fortify Assura DR Quadra Assura CRT-D

1.5T MRI image scans

Leads

LPA1200M 7122Q 1458Q

1.5T MRI image Scans

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Leadless Devices

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Leadless Devices

u Eliminate/reduce pocket and lead complications seen with traditional pacemakers.

u Safe pacing option for those patients who have had a device infections.

Leadless Devices

u Delivered through a transcutaneous approach. u 99.1% implant success rate. u Low dislodgement rate(0.06%) u Low infection rate (0.17%) u Retrieval feature for acute retrieval. u 87% relative risk reduction in system revisions. 54% fewer hospitalizations.

Leadless Devices

Leadless Devices:

Leadless Devices:

u Preferred choice for: u Patients 65 and younger who lead an active lifestyle. u Have no venous access u Are diagnosed with Channelopathies(LQT, Burguda, HCM) u High risk for complications with TV-ICD. u Have high risk of infections and history of endocarditis.

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