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CIED implant trouble shoot in cath. room
Allied Professional Training, THRS
19st, Oct, 2013
黃鴻儒 醫師
Classification of Pacemaker Complications by Clinical Presentation
Implant related complication
Post-implant complication
New symptoms secondary to PPM
Asymptomatic ECG abnormalities
Pneumothorax ( due to subclavian punctureOther complications of subclavian punctureHematoma Lead perforationLead dislodgmentLead placement in the systemic circulation
Lead fractureLead insulation defectLoose lead connectorTwiddler syndrome
Extracardiac stimulationPacemaker syndromePacemaker mediated tachycardiaInfectionPain
Failure to captureFailure to senseOversensing (failure to output)Change in paced rate
Pneumothorax Hemothorax Pneumo- hemothorax Brachial plexus injury Arterial puncture Chylothorax Infection Pocket Hematoma / Seroma
Implantation Techniques - Acute
Acute Venous Stenosis Limiting Access
Pneumothorax In PASE Trial: 1.97%
Acute Hemothorax Complicating Subclavian Venipuncture
Within 15 minutes of subclavian arterial puncture
3 hours post-procedure
Management for Pneumothorax Suspect lung puncture withdraw the needle, wait a
moment to make certain that a rapid-onset, large, markedly symptomatic pneumothorax is not occurring.
If a pneumothorax does develop, it may not even be apparent radiographically at the end of the procedure.
If a lung puncture has occurred, obtaining another upright chest radiograph 6 hours after completion of the procedure is advisable.
If a pneumothorax has developed, a chest tube or catheter evacuation procedure may be necessary, although frequently, a small to moderate pneumothorax that is not expanding can be managed conservatively without evacuation.
Avoid air embolism (esp. for large-bored sheaths)
press proximal end of sheath and instruct patient to hold breath during pacing lead insertion
use of introducer sheath with hemostatic valve
Air Embolism during Permanent Pacemaker Procedures
Prevention of Air Embolism during PPM Procedures
Myocardial Perforation
When recognized, lead MUST be pulled back ?!
Be prepared for tamponade May require open procedure
to manage but heart usually seals itself.
Diaphragmatic Stimulation Lead in Cardiac Vein
Lead inadvertently placed into post. Cardiac V
Recorded immediately post-implant.
The atrial sensing threshold was 1.8 mV, the ventricular sensing threshold was 12 mV
What is the cause of this behavior?
Implantation Procedure #1
As Vp Vs As Vp
Marker of pacemaker
Implantation Procedure #1
P wave marker is above a QRS
R wave marker is above a P-wave
Leads are switched in the header
As Vp As VpVs
Implantation Procedure #2
The tracing shown below was recorded with the pacemaker in the DDD mode, 4 V output on both atrial and ventricular channels, base rate 60 ppm and AV delay 165 ms. What is the problem if any?
Surface ECG
Marker
A IEGM
A : A pacing
V : V pacing
Implantation Procedure #2
Loss of V capture
Loss of V capture
Loss of V capture
Loss of V capture
Loss of V-capture, Patient is in a 2:1 heart block, need to recheck the V lead position.
A : A pacing
V : V pacing
Implantation Procedure #3
The device is hooked up and the following ECG is seen. Is this normal? If not, what is occurring?
A : A pacing
P : A Sensing
V : V Pacing
R : V Sensing
Implantation Procedure #3
A pacing with V sense to follow
A pacing with V sense to follow
Good A capture
Implantation Procedure #3
PVC
PVC falls upon the AP which V pacing follows inducing the loss of AV synchrony
PMT
Pacemaker-Mediated Tachycardia
Retrograde P
PMT at Max Track Rate (or Slower)
Ventricular Channel Must Respond
Initiated by a loss of AV synchrony PVC most common cause Atrial loss of capture Atrial undersensing PAC Magnet removal
How to terminate PMT Place magnet Change to VVI (Use programmer) Program longer PVARP (Use programmer) Use PMT termination algorithm (pacemaker function)
Auto-Detect Algorithm
Retrograde P
PMT terminated
Implantation Procedure #4
This ECG strip is handed to you post implant. What is the most likely diagnosis?
Implantation Procedure #4
Ap Vp Ap Vp Ap Vp Ap Vp
Normal AV delay
Short AV delay (120 ms) : Safety pacing
Ap Vp
1. A pacing and accompany with captured QRS, it indicated A lead dislodge to ventricle.
2. No V captured waveform followed by V pacing spike due to ventricular is in the physical refractory.
3. On occasion, AV delay is short because of safety pacing.
atrial lead in the ventricle
Implantation Procedure #4
Pulse Generator Pocket- Chronic Pain - pocket neuralgia
Incorrect tissue plan Incorrect location - too lateral Smoldering infection
Erosion Pressure necrosis Smoldering infection
Migration Twiddler’s Syndrome
Bipolar
In-line Bipolar conductor construction Two Coils
Will have several strands Trifiler, Quadrafiler, 5 filer, etc.
Two layers of Insulation
Outer insulationOuter coil
(Anode)
Inner insulation
Inner coil(Cathode )
Conductor Coil Fracture
Rib-Clavicle crushInsulation damage
Conductor fracture
Tight anchoring sleeveInsulation damage
Conductor fracture
Loose anchoring sleeve Lead dislodgment
Twiddler’s Syndrome
Implantation Techniques - Late
Rib-Clavicle CrushInsulation Damage
Insulation is radiolucent, deformity in conductor coil identifies location of problem
Rib-Clavicle Crush- Conductor Fracture
Dotted line identifies lower edge of clavicle
Loose Anchoring SleeveTwiddler’s Syndrome
Loose Anchoring Sleeve
Lead allowed to “pull back”
Traction at electrode-tissue interface causes high thresholds
Predispose to dislodgment
Note loss of heel on leads
Loose Anchoring Sleeve Dual Lead Dislodgment
Day 1 post-implant
July 2001
Day 3 post-implant
Tight Anchoring SleeveDamage to Lead
Tight Anchoring Sleeve
Leads from 4 different mfg’s
Tight anchoring sleeve pushes insulation between conductor coils “pseudofracture”
Areas of major stress
Myocardial perforation (Pacemaker lead perforation rate: 0.1~0.8%, ICD lead perforation rate : 0.6~5.2%)
Placement in left ventricle via Patent foramen ovale Septal perforation Arterial entry
Dislodgment: The most common complication( PAcemaker Selection in Elderly : 2.2%) Atrial dislodgment : 3% Ventrical dislodgement : below 2%
Diaphragmatic stimulation Directly - lead in cardiac vein Directly - myocardial perforation Indirectly - phrenic nerve stimulation
Pacemaker Lead Placement
Venous thrombosisSuperior vena cava syndrome
Pulmonary embolism Systemic embolism
Endocardial lead on left side of circulation
Paradoxical embolism
Thrombotic Problems
Venous Thrombosis
Chronic thrombosis with collaterals
SVC Syndrome
Chronic Venous Thrombosis
Superficial dilated veins in upper extremity and chest
Localized to side of chest where pacemaker is located
No specific treatment
July 2001
Superior Vena Cava Syndrome
Symptoms Swelling of arms Fullness in head &
neck Increased JVP
Management Anticoagulation Surgical reconstruction Lead explantation Venoplasty &
Stent placement
“Beaver Syndrome”
Management of Pocket Hematoma
Observation and close follow-up Soft Minimal to no
tenderness Surgical evacuation
Tense pocket threatening suture line
Weeping suture line Severe pain Immunocompromised
host August 2001
Pain - pocket neuralgia
Incorrect tissue plane
Incorrect location - too lateral
Smoldering infection Erosion
Pressure necrosis
Smoldering infection
Incorrect location
too lateral
too superficial Migration Twiddler’s Syndrome
Pulse Generator Pocket - Chronic
PAIN Incorrect Tissue Plane
Furman S, PACE 2001; 24: 1224-1227
Proper Location of Pulse Generator
Furman S, PACE 2001; 24: 1224-1227
Note the use of the Cephalic Vein! Pocket is then placed medial to the incision on the anterior chest wall.
Improper Location of Pulse Generator
Furman S, PACE 2001; 24: 1224-1227
If the pacemaker is placed too lateral, it will cause discomfort every time the patient rotates arm forward
Pressure Necrosis
Thinning and discoloration at lateral margin
Total breakdown and 2° Infection
Smoldering Pocket Infection with draining fistula
Presented 2 years post implant
Eschar and draining fistula at edge of incision, surrounding erythema
Waxed and waned on oral antibiotics
Local cultures were negative
January 24, 2002
Chronic Smoldering InfectionPulse Generator Explanted but Not Lead
Low grade pocket infection Managed by explanting
pulse generator but leaving lead in place
2 weeks of antibiotics Initial good result MUST remove all foreign
material from pocket
9 months post-PG explant
Pacemaker Extrusion
Parsonnet V, Circulation 2000; 102: 1192
Clinical history: 61 year old man implanted 9 months previously for complete heart block. Did not consider follow-up to be necessary. Not concerned when device began to show through the skin. Only when it fell out did he call his physician. Cultures grew Staph epidermidis. Unknown if a primary infection caused the erosion or the site was secondarily infected once it was open to the skin.
Electromagnetic Interference Electromagnetic Interference (EMI) involves electrical
and/or magnetic signals in the environment or arising from the body that impact the normal function of the implanted pacing system.
Microwave ovens Cellular telephones Electronic article surveillance Power stations Arc welding equipment CB and Ham Radio equipment
Community Based EMI Influences
Cardioversion and DefibrillationExternal
Internal
Electrocautery Transcutaneous Electrical Nerve
Stimulators (TENS) Magnetic Resonance Imaging (MRI) Radiation Therapy (XRT) Electroconvulsive Therapy (ECT)
Hospital Based EMI Influences
TemporaryNoise mode reversion
Inhibition - sensing
Programming change
PermanentDamage to pulse generator
Tissue damage at electrode -myocardial interface
Increase in capture threshold
Increase in sensing threshold
Lead damage
Patient injury
Potential Effects of EMI
THANKS
THANKS
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