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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...
Implantation Techniques - Acute
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Pneumothorax
Hemothorax
Pneumo- hemothorax
Brachial plexus injury
Arteria...
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 postproc...
Management for Pneumothorax
 Suspect lung puncture  withdraw the needle, wait a
moment to make certain that a rapid-onse...
Air Embolism during Permanent Pacemaker
Procedures

 Avoid air embolism (esp. for largebored sheaths)
 press proximal en...
Prevention of Air Embolism during PPM Procedures
Myocardial Perforation
 When recognized, lead MUST
be pulled back ?!
 Be prepared for tamponade
 May require open proce...
Diaphragmatic Stimulation
Lead in Cardiac Vein

Lead inadvertently placed into post.
Cardiac V
Implantation Procedure #1
Recorded
immediately postimplant.
The atrial sensing
threshold was 1.8
mV, the ventricular
sensi...
Implantation Procedure #1

P wave marker
is above a QRS
As Vp

R wave marker
is above a Pwave
Vs

As Vp

Leads are switche...
Implantation Procedure #2
The tracing shown below was recorded with the pacemaker in
the DDD mode, 4 V output on both atri...
Implantation Procedure #2
Loss of V-capture, Patient is in a 2:1 heart block, need to recheck
the V lead position.
Loss of...
Implantation Procedure #3
The device is hooked up and the following ECG is
seen. Is this normal? If not, what is occurring...
Implantation Procedure #3
Good A capture

A pacing with
V sense to
follow

A pacing with
V sense to
follow
Implantation Procedure #3

PVC falls upon the AP which V
pacing follows inducing the loss
of AV synchrony
PVC

PMT
Pacemaker-Mediated Tachycardia
 Initiated by a loss of AV synchrony
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PVC most common cause
Atrial loss of captu...
How to terminate PMT
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Place magnet
Change to VVI (Use programmer)
Program longer PVARP (Use programmer)
Use PMT te...
Implantation Procedure #4
This ECG strip is handed to you post implant. What is
the most likely diagnosis?
Implantation Procedure #4
1. A pacing and accompany with captured QRS, it indicated A lead
dislodge to ventricle.
2. No V ...
Implantation Procedure #4

atrial lead
in the ventricle
Pulse Generator Pocket- Chronic


Pain - pocket neuralgia
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Erosion
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

Incorrect tissue plan
Incorrect lo...
Bipolar
 In-line Bipolar conductor construction
 Two Coils
 Will have several strands
 Trifiler, Quadrafiler, 5 filer,...
Conductor Coil Fracture
Implantation Techniques - Late


Rib-Clavicle crush
Insulation damage
Conductor fracture



Tight anchoring sleeve
Insul...
Rib-Clavicle Crush
Insulation 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 Sleeve
Twiddler’s Syndrome
Loose Anchoring Sleeve

 Lead allowed to “pull
back”
 Traction at electrodetissue interface causes
high thresholds
 Pre...
Loose Anchoring Sleeve
Dislodgment

Dual Lead

July 2001

Day 1 postimplant

Day 3 postimplant
Tight Anchoring Sleeve
Damage to Lead
Tight Anchoring Sleeve

 Leads from 4 different
mfg’s
 Tight anchoring sleeve
pushes insulation
between conductor
coils ...
Pacemaker Lead Placement
 Myocardial perforation (Pacemaker lead perforation rate:
0.1~0.8%, ICD lead perforation rate : ...
Thrombotic Problems



Venous thrombosis
Superior vena cava syndrome

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Pulmonary embolism
Systemic embolism
Endocardi...
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
pace...
Superior Vena Cava Syndrome
 Symptoms
 Swelling of arms
 Fullness in head &
neck
 Increased JVP
 Management
 Anticoa...
Management of Pocket Hematoma

 Observation and close
follow-up
 Soft
 Minimal to no
tenderness
 Surgical evacuation
...
Pulse Generator Pocket - Chronic


Pain - pocket neuralgia
Incorrect tissue plane
Incorrect location - too lateral
Smolde...
PAIN
Incorrect Tissue Plane

Furman S, PACE 2001; 24: 1224-1227
Proper Location of Pulse Generator

Note the use of the
Cephalic Vein! Pocket
is then placed medial to
the incision on the...
Improper Location of Pulse Generator

If the pacemaker is
placed too lateral, it
will cause discomfort
every time the pati...
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 o...
Chronic Smoldering Infection
Pulse Generator Explanted but Not Lead

 Low grade pocket infection
 Managed by explanting
...
Pacemaker Extrusion

Clinical history: 61 year old
man implanted 9 months
previously for complete heart
block. Did not con...
Electromagnetic Interference
 Electromagnetic Interference (EMI) involves electrical
and/or magnetic signals in the envir...
Community Based EMI Influences
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Microwave ovens
Cellular telephones
Electronic article surveillance
Power stat...
Hospital Based EMI Influences
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Cardioversion and Defibrillation
External
Internal

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Electrocautery
Transcutan...
Potential Effects of EMI


Temporary
Noise mode reversion
Inhibition - sensing
Programming change



Permanent
Damage to...
THANKS
THANKS
心臟植入性電子儀器(CIED)護理照護指引-Cathroom Troubleshooting_20131019南區
心臟植入性電子儀器(CIED)護理照護指引-Cathroom Troubleshooting_20131019南區
心臟植入性電子儀器(CIED)護理照護指引-Cathroom Troubleshooting_20131019南區
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心臟植入性電子儀器(CIED)護理照護指引-Cathroom Troubleshooting_20131019南區

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心臟植入性電子儀器(CIED)護理照護指引-Cathroom Troubleshooting_20131019南區

  1. 1. CIED implant trouble shoot in cath. room Allied Professional Training, THRS 19st, Oct, 2013 黃鴻儒 醫師
  2. 2. 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 puncture Other complications of subclavian puncture Hematoma Lead perforation Lead dislodgment Lead placement in the systemic circulation Lead fracture Lead insulation defect Loose lead connector Extracardiac stimulation Pacemaker syndrome Pacemaker mediated tachycardia Infection Pain Failure to capture Failure to sense Oversensing (failure to output) Change in paced rate Twiddler syndrome
  3. 3. Implantation Techniques - Acute         Pneumothorax Hemothorax Pneumo- hemothorax Brachial plexus injury Arterial puncture Chylothorax Infection Pocket Hematoma / Seroma
  4. 4. Acute Venous Stenosis Limiting Access
  5. 5. Pneumothorax  In PASE Trial: 1.97%
  6. 6. Acute Hemothorax Complicating Subclavian Venipuncture Within 15 minutes of subclavian arterial puncture 3 hours postprocedure
  7. 7. 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.
  8. 8. Air Embolism during Permanent Pacemaker Procedures  Avoid air embolism (esp. for largebored sheaths)  press proximal end of sheath and instruct patient to hold breath during pacing lead insertion  use of introducer sheath with hemostatic valve
  9. 9. Prevention of Air Embolism during PPM Procedures
  10. 10. Myocardial Perforation  When recognized, lead MUST be pulled back ?!  Be prepared for tamponade  May require open procedure to manage but heart usually seals itself.
  11. 11. Diaphragmatic Stimulation Lead in Cardiac Vein Lead inadvertently placed into post. Cardiac V
  12. 12. Implantation Procedure #1 Recorded immediately postimplant. The atrial sensing threshold was 1.8 mV, the ventricular sensing threshold was 12 mV As Vp Vs As Vp Marker of pacemaker What is the cause of this behavior?
  13. 13. Implantation Procedure #1 P wave marker is above a QRS As Vp R wave marker is above a Pwave Vs As Vp Leads are switched in the header
  14. 14. 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
  15. 15. Implantation Procedure #2 Loss of V-capture, Patient is in a 2:1 heart block, need to recheck the V lead position. Loss of V capture A : A pacing V : V pacing Loss of V capture Loss of V capture Loss of V capture
  16. 16. 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
  17. 17. Implantation Procedure #3 Good A capture A pacing with V sense to follow A pacing with V sense to follow
  18. 18. Implantation Procedure #3 PVC falls upon the AP which V pacing follows inducing the loss of AV synchrony PVC PMT
  19. 19. Pacemaker-Mediated Tachycardia  Initiated by a loss of AV synchrony      PVC most common cause Atrial loss of capture Atrial undersensing PAC Magnet removal Retrograde P Ventricular Channel Must Respond PMT at Max Track Rate (or Slower)
  20. 20. How to terminate PMT     Place magnet Change to VVI (Use programmer) Program longer PVARP (Use programmer) Use PMT termination algorithm (pacemaker function) Retrograde P PMT terminated Auto-Detect Algorithm
  21. 21. Implantation Procedure #4 This ECG strip is handed to you post implant. What is the most likely diagnosis?
  22. 22. Implantation Procedure #4 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. Short AV delay (120 ms) : Safety pacing Normal AV delay Ap Vp Ap Vp Ap Vp Ap Vp Ap Vp
  23. 23. Implantation Procedure #4 atrial lead in the ventricle
  24. 24. Pulse Generator Pocket- Chronic  Pain - pocket neuralgia     Erosion     Incorrect tissue plan Incorrect location - too lateral Smoldering infection Pressure necrosis Smoldering infection Migration Twiddler’s Syndrome
  25. 25. Bipolar  In-line Bipolar conductor construction  Two Coils  Will have several strands  Trifiler, Quadrafiler, 5 filer, etc. Inner insulation  Two layers of Insulation Outer insulation Outer coil (Anode) Inner coil (Cathode )
  26. 26. Conductor Coil Fracture
  27. 27. Implantation Techniques - Late  Rib-Clavicle crush Insulation damage Conductor fracture  Tight anchoring sleeve Insulation damage Conductor fracture  Loose anchoring sleeve Lead dislodgment Twiddler’s Syndrome
  28. 28. Rib-Clavicle Crush Insulation Damage Insulation is radiolucent, deformity in conductor coil identifies location of problem
  29. 29. Rib-Clavicle Crush- Conductor Fracture Dotted line identifies lower edge of clavicle
  30. 30. Loose Anchoring Sleeve Twiddler’s Syndrome
  31. 31. Loose Anchoring Sleeve  Lead allowed to “pull back”  Traction at electrodetissue interface causes high thresholds  Predispose to dislodgment Note loss of heel on leads
  32. 32. Loose Anchoring Sleeve Dislodgment Dual Lead July 2001 Day 1 postimplant Day 3 postimplant
  33. 33. Tight Anchoring Sleeve Damage to Lead
  34. 34. Tight Anchoring Sleeve  Leads from 4 different mfg’s  Tight anchoring sleeve pushes insulation between conductor coils “pseudofracture”  Areas of major stress
  35. 35. Pacemaker Lead Placement  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
  36. 36. Thrombotic Problems  Venous thrombosis Superior vena cava syndrome   Pulmonary embolism Systemic embolism Endocardial lead on left side of circulation Paradoxical embolism
  37. 37. Venous Thrombosis Chronic thrombosis with collaterals SVC Syndrome
  38. 38. 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
  39. 39. 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”
  40. 40. 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
  41. 41. Pulse Generator Pocket - Chronic  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
  42. 42. PAIN Incorrect Tissue Plane Furman S, PACE 2001; 24: 1224-1227
  43. 43. Proper Location of Pulse Generator Note the use of the Cephalic Vein! Pocket is then placed medial to the incision on the anterior chest wall. Furman S, PACE 2001; 24: 1224-1227
  44. 44. Improper Location of Pulse Generator If the pacemaker is placed too lateral, it will cause discomfort every time the patient rotates arm forward Furman S, PACE 2001; 24: 1224-1227
  45. 45. Pressure Necrosis Thinning and discoloration at lateral margin Total breakdown and 2° Infection
  46. 46. 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
  47. 47. Chronic Smoldering Infection Pulse 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
  48. 48. Pacemaker Extrusion 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. Parsonnet V, Circulation 2000; 102:
  49. 49. 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.
  50. 50. Community Based EMI Influences       Microwave ovens Cellular telephones Electronic article surveillance Power stations Arc welding equipment CB and Ham Radio equipment
  51. 51. Hospital Based EMI Influences  Cardioversion and Defibrillation External Internal      Electrocautery Transcutaneous Electrical Nerve Stimulators (TENS) Magnetic Resonance Imaging (MRI) Radiation Therapy (XRT) Electroconvulsive Therapy (ECT)
  52. 52. Potential Effects of EMI  Temporary Noise mode reversion Inhibition - sensing Programming change  Permanent Damage to pulse generator Tissue damage at electrode -myocardial interface Increase in capture threshold Increase in sensing threshold Lead damage Patient injury
  53. 53. THANKS
  54. 54. THANKS

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