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

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