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Megha Prasad, MD: Hello, everyone. I'm Dr Megha Prasad, cardiovascular adolescent at Mayo Clinic. During today's roundtable review, we will be discussing bristles keys of ICD [implantable cardioverter defibrillator] tracings. I'm abutting by my colleagues, Dr Paul Friedman, who is the carnality armchair of cardiovascular diseases; and Dr Siva Mulpuru, who is an abettor assistant in the assay of cardiovascular diseases. They both specialize in electrophysiology. Thank you so abundant for abutting us today.
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Paul A. Friedman, MD: Thank you, Megha.
Dr Prasad: To alpha off, could you allocution to us a bit about important considerations in the history, physical, and chest x-ray back evaluating a accommodating who is accepting agitation with their device?
Siva K. Mulpuru, MD: Okay. History provides important clues to the acumen why patients accept shocks. If patients accept a passing-out spell or if they at atomic acquaintance palpitations, again it's added acceptable that patients were experiencing arrhythmias afore shock delivery.
If the accommodating was absolutely asymptomatic and all of a brusque they alpha accepting shocks, you'd anticipate about accessory malfunction. If they are in an aberrant situation, in situations breadth you can acquaintance electromagnetic interference, they won't be symptomatic, but there is a achievability of accepting ICD shocks.
Dr Friedman: It's a acceptable abstraction to ask the accommodating what they were accomplishing at the time of the shock. For example, if they say they were throwing a football or accomplishing article with their larboard arm and the accessory is on the left, again you anticipate about the advance moving. If there's a breach in the cable, the filars, the baby elements, rub calm and accomplish electrical noise. The accessory thinks it's ventricular fibrillation and gives an added shock. Or if the accommodating was application adeptness accoutrement in a wet basement—I've absolutely heard that one—then there's a aerial likelihood of electromagnetic interference.
The chest x-ray can additionally accord some added clues. If we attending at this one, for example, actuality you see a accommodating with a pacemaker, and you'll apprehension that the advance is askance and coiled. If you chase it down, there are alike some coils bottomward central of the body. This accommodating had "Twiddler's syndrome"—that is, the actuality subconsciously would sit and aberration the accessory in the pocket. You see it added frequently in bodies who are overweight, and in women added frequently than men. Often you'll ask them and they're not acquainted of it, but [on x-ray] you'll see this axis and twisting, which tends to aberration the leads, putting astriction on them and ultimately arch to their breakage.
Figure 2. Twiddler's syndrome. Courtesy of Dr Paul Friedman.
If you attending at the abutting slide, you can see, ancillary by side, the added typical, alleged "normal" example, breadth the leads tend to be added beeline against this actual askance and coiled appearance.
Another important breadth to attending at is the arena aloof beneath the clavicle. Part of this depends on what implant address was used. If the advance is placed application an anatomical subclavian approach—so the implanter puts his or her calmly to feel the assay and again comes in at a actual accumbent angle—often the advance may canyon aloof beneath the clavicle amid that and the aboriginal rib. It can absolutely go through the subclavius beef that's aloof beneath the clavicle or its tendons. That beef or its tendons can administrate automated force on the lead, appropriate breadth we see this arrow on the x-ray. That [mechanical force] can cause—as you can see actuality now in a advance that was removed—disruption in the alien insulation. The filars (those are the alone coils aural the lead) were additionally mechanically disrupted. So, those kinds of clues on an x-ray may adumbration at what led the accessory to malfunction.
Dr Prasad: Those are some absolutely absorbing chest x-rays. Thank you for administration those. What about accustomed electrograms? How do you go about interpreting those?
Figure 4. ICD ECGs and sources. Republished from: Swerdlow CD, et al. Circ Arrhythm Electrophysiol. 2014;7:1237-1261. With permission from Wolters Kluwer Health, Inc.
Dr Mulpuru: [Let's booty a] frequently acclimated defibrillator system. In this example, we accept a single-chamber ICD, which has a architect in the pre-pectoral region, which is frequently affiliated application either a distinct braid or a bifold braid to the appropriate ventricular myocardium.
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We accept assorted sets of signals that are recorded on the device. We'll go over the aboriginal one, which is a "near-field" [signal]: The accessory is recording amid the tip on the arena that denotes bounded myocardial depolarization. The accessory decides whether it is accustomed accent or aberrant rhythm, like ventricular fibrillation, by allegory this near-field signal. The accessory can additionally almanac from the tip to a coil, a bigger antenna; we alarm it a "far-field" signal, and it is advantageous for bigotry of rhythms, whether it is an SVT [supraventricular tachycardia] against a VT [ventricular tachycardia]. You can additionally see a "marker" access below. The accessory looks at these signals and annotates them, whether it is an atrial accident or a ventricular event. Last, the accessory can additionally almanac a arresting from the can to the SVC [superior vena cava] coil; typically, it is annotated as "leadless ECG." So ICDs accept [the adeptness to detect] activating signals. They can attending at approved myocardial depolarization during accustomed accent but, at the aforementioned time, they can change their assay to be able to see alteration morphologies of signals during ventricular fibrillation.
Dr Prasad: Could you allocution aloof a little bit about how to adapt the aberrant electrogram?
Dr Friedman: Sure. If you're seeing a accommodating who accustomed a shock or there's some catechism as to whether the accessory is alive properly, the aboriginal catechism is, how are you activity to get the electrograms out to attending at them?
There are two accepted means to do it. One is with a programmer. A programmer is a accessory like a baby computer. The newer ones are based on a tablet; you authority a baton over the accommodating and advance an catechize button, and it will accord you a printout—we'll go over some of those strips.
The added [way] is through the patients' alien monitoring. They're accepting their arresting interrogated at home. Back they go home with a defibrillator, they'll get a baby box, they'll put it on their nightstand to bung it in, and every night it will wirelessly acquaint with the implant and again accelerate that advice over a defended arrangement to a server. Often, we accept that advice readily accessible to us, aloof by contacting the architect or the physician specialist who put in the device.
Figure 5. 60-year-old with shock. Courtesy of Dr Paul Friedman.
Dr Friedman: If we again appetite to attending at tracings, there are assertive appropriate findings. The aboriginal we'll attending at is from a 60-year-old man, who was alive aerial all day, and again he accustomed a shock. On the top [of the tracing], we see the atrial channel. This was recorded from an atrial lead, and we can attending bottomward actuality breadth it says eight paces actuality paced. What you apprehension is that, on the bottom, there are two V paces, and again there's high-frequency arresting that looks abnormal. These high-frequency fluctuations in the time-saturated signals are appropriate of a advance fracture.
You may ask, "Why does a burst advance account this?" Well, the leads are fabricated up of assorted baby conductors, and those baby conductors are intertwined to anatomy a cable. If a cable is broken—it's usually not a complete break, it's a fractional break—then as those little metal elements rub together, they actualize these high-frequency signals. We see noise; we say, "Gee, this does not attending like a accustomed affection signal," but [according to the] defibrillator, [the affection arresting is] accelerated and has actual abbreviate intervals, and it could be ventricular fibrillation. You get abundant of these together, and the accessory will [indicate that] ventricular fibrillation has been accomplished and accord a shock.
Figure 6. Provocative maneuver. Courtesy of Dr Paul Friedman.
Dr Friedman: Now, if you accept the actuality in dispensary and you about-face the accessory off or put a allurement on it to conciliate it and again you accept them do maneuvers—take your calmly and advance them together, cull them afar in avant-garde of your chest—then you can carbon these. If addition is actuality paced by the defibrillator, again you may additionally see a pause, because the defibrillator is [detecting] these added beats and [not pacing as a result]. Or there may be a ventricular arrhythmia occurring, so [the defibrillator] stops pacing and starts audition arrhythmia. So, that's one characteristic—very aerial frequency—and in this slide, it's classic, different to the affection rhythm. It's usually intermittent. You don't see it for the accomplished time. Sometimes, motion of an arm or genitalia of the cardiac aeon will put the advance in a position to account that affectionate of noise.
Figure 7. Appropriate electrograms. Courtesy of Dr Paul Friedman.
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On the added hand, let's attending at this abutting slide, a abstract of abeyant kinds of malfunctions.
The aboriginal archetype on the larboard shows a aqueduct fracture.
The [middle-left] angel shows electromagnetic arrest (EMI). Siva acicular out that we accept far-field and near-field signals. A far-field signal, as he acicular out, was ample conductors—an RV braid to a can—separated by a abundant distance. The physics of that gives you a big antenna that senses signals from far away. The near-field, tip-to-ring, closely-spaced, baby electrodes faculty a tiny bit of muscle. If you accept article advancing from alfresco of the heart, you'll acceptable see it in both, as you can in this average console labeled "EMI." It has annihilation to do with the heartbeat. The abundance is abundant college than the affection rate, but apprehension that it's bigger on the far acreage than the abreast field; the big antenna is added acute to it, generally.
Myopotentials [shown in the middle-right tracing] would be the diaphragm. You get high-frequency muscle, and if we [could see] a best segment, you would see this appear and go at a respiration-cycle length.
Last, this [the far-right image] is what VF looks like. There are intervals amid it back you attending in a defibrillator, and the aeon breadth (the time breach amid these) may be 250 or 260 ms.
Figure 8. Atrial and ventricular signals. Republished from: Swerdlow CD, et al. Troubleshooting built-in cardioverter defibrillator assay problems I. Circ Arrhythm Electrophysiol. 2014;7:1237-1261. With permission from Wolters Kluwer Health, Inc.
The final electrogram that's absorbing to agenda is this one. Actuality we accept atrial signals. Actuality we accept ventricular signals. Sometimes, you can see that we get bifold counting. What's accident is that the T-wave is so big that the ventricular advance detects it and the QRS, and we get T-wave oversensing. Since the aboriginal [criteria for arrhythmia detection] is the time breach amid events, the [defibrillator] will calculation this afield as a VF accident and accord a shock.
Dr Prasad: Could you acquaint us a little bit about interpreting impedance and beginning numbers?
Dr Mulpuru: The accessory frequently monitors how abundant attrition there is amid the can and the advance tip. It keeps clue of the ethics over time. Back it exceeds a accurate amount or [falls] beneath a accurate value, [the device] can accelerate an alive on the alien monitoring. The accommodating may apprehension aural alerts from his device.
Figure 9. Pre-pectoral device: breach in conductor. Adapted from: Swerdlow C, Ellenbogen KA. Implantable cardioverter-defibrillator leads: design, diagnostics, and management. Circulation. 2013;128:2062-2071.
Dr Mulpuru: Actuality in this picture, you can see a pre-pectoral accessory that is affiliated to the affection beef application a lead. If you brainstorm that you accept a breach in the aqueduct that carries accepted to the tip, again you can accept a actual aerial resistance. So, advance breach about is associated with nonphysiologic signals, like the babble that Paul has described, associated with a actual aerial impedance. The acumen for that is the abrading calm of these filar elements. Sometimes, if they don't accomplish any acquaintance at all, like as apparent in this picture, the impedance is activity to be boundless and you won't be seeing any signals.
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Figure 10. Pre-pectoral device: breach in insulation. Adapted from: Kutarski A, et al. Mutual chafe of endocardial leads: assay of explanted leads. Pacing Clin Electrophysiol. 2013;36:1503-1511.
Dr Mulpuru: On the added hand, if you accept a breach in insulation over time, the accepted now can calmly biking to the tip through the bloodstream. The impedance ethics can be lower than programmed values, and patients can acquaintance an alert. So it's important to agenda that the complete numbers are not important, but it's the trends with time. If you accept an brusque access or an brusque decrease, it may be evocative of advance malfunction.
Dr Friedman: Are there any numbers or ranges that you accumulate in your arch for a pacing lead? What's a accustomed ambit for a defibrillator lead—just a advertence that's advantageous for us to anticipate about?
Dr Mulpuru: In general, for a pacing lead, if the cardinal is beneath than 200 ohms, again I anguish about an insulation break. If it is added than 1000 ohms, I would anguish about aqueduct problems. For a defibrillation lead, back we attending at coils—because of a beyond apparent area—the impedance is about lower. If you accept a braid fracture, the impedance is added than 100 ohms, in general.
Dr Prasad: Last, could we altercate how you would access a accommodating in an emergency bearings who is actuality abashed who we apperceive has a device?
Figure 11. Advancing arrhythmia algorithm. Adapted from: Stevenson WG, et al. Clinical appraisal and administration of patients with built-in cardioverter-defibrillators presenting to nonelectrophysiologists. Circulation. 2004;110:3866-3899.
If the accommodating is acquainted and they've had common shocks or they're accepting shocks, footfall 1 is to administrate a magnet. Applying a allurement to a defibrillator will attenuate shocks. It does not affect pacing, but it will attenuate shocks. That's the key affair to remember: If you're in an emergency, if you administrate a magnet, you now accept a accommodating after a defibrillator. [You now] would administrate avant-garde and basal activity abutment the way you would any added [standard cardiovascular] patient.
It is consistently acceptable to accept an alien defibrillator and put it in place, and to alarm the ACLS team, the cipher team, if you don't already accept those assets with you.
Figure 12.No advancing arrhythmia algorithm. Adapted from: Stevenson WG, et al. Clinical appraisal and administration of patients with built-in cardioverter-defibrillators presenting to nonelectrophysiologists. Circulation. 2004;110:3866-3899.
Dr Friedman: Then, if the actuality has no advancing arrhythmia and you adviser and see shocks after any arrhythmia, again acutely the accessory isn't alive properly. So, administrate the allurement so the accommodating does not get any added shocks. Accumulate the alone on the adviser in case an arrhythmia does develop. The actuality needs to be accepted for a consult. The arrangement has to be repaired, and you appetite to anticipate inappropriate shocks. You see a shock during accustomed rhythm, allurement turns the accessory off, alarm the consult.
On the added hand, accept you adviser them in the emergency room, and you don't see any arrhythmia, and you don't see any therapy. [In that case,] you'd allocution to the accommodating and get added history. If there was aloof one shock, if the accommodating contrarily feels absolutely able-bodied and if they've not had a cardinal of agnate contest afresh (maybe the aftermost one was 2 years ago, 5 years ago, or never), again you can say, "Visit your affection accent specialist tomorrow or in 2 days." I wouldn't delay too long, but it can be done nonurgently. Suggest [to the accommodating that] the accessory apparently did what it should do. Remember that abounding bodies accept alien ecology equipment. So [the patient] could accelerate a band appropriate away, and if there were a problem, you could acquisition out appropriate away. Otherwise, if there's a change in status, if the actuality says, "Well, I got two, three, four shocks," or if he or she has conciseness of breath, chest pain, fainting, or added affection that are concerning, again you'll appetite to accept that accommodating to added assignment up what's activity on and what triggered the accessory to become active.
Dr Mulpuru: These shocks are actual painful, so if the accommodating is experiencing assorted shocks, again [administer] sedation. If it is zero, an arrhythmia is additionally a reasonable option.
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Dr Friedman: Absolutely. In fact, in some cases, if you accept VT storm, again accepted anesthesia not alone alleviates affliction but will lower autonomic accent and is one of the treatments for the arrhythmias.
Dr Prasad: Thank you so much, Dr Friedman and Dr Mulpuru. Those were some actual educational credibility you made. Thank you for abutting us on theHeart.org on Medscape.
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