CIED Follow Up week 5

Programmers

Tool for communicating with patient’s device

access data

program changes

Unique to each company

Common components/features

Hardware

Power cord: universal for most

Power button: typically back left

Emergency buttons: stat pace/shock

Printer: buttons and paper change

Pacing system analyzer (and adapter)

Other cables: VGA, ECG

Other features: keyboard, stylus

Wand: external antenna for wireless? magnet or no magnet?

When/Where is a Programmer Used?

Emergency room

Telemetry unit

Before/after procedures

MRI conditional pacemakers: require programming changes

Implant, lead extraction, lead revision, gen change

Reducing Device Rep Burden

effort to train hospital staff

devices with automatic changes

Point of care monitors

on site interrogation

off site expert reviews/guides

Device Clinic

in person evaluation

previously every 3-6 months

remote monitoring:

much greater survival

gold standard of care

less frequent IPEs: at least once a year

Follow Up: Set Up

turn programmer on

position programmer to see patient

attack ECG leads

Hospital: slave into monitor

Clinic: may use electrodes or intracardiacs only

Follow Up: Wound Check

check site of implant

look for signs of infection

acute and chronic setting

device may erode through skin

Follow Up: Interrogation

place wand over device

left shoulder, right shoulder, abdomen

submuscular implants: deeper

wand may have lights

can remove wand once connected to wireless device

Reasons for Follow Up

general assessment of device

patient’s underlying rhythm

run tests

analyze diagnostics

patient symptoms

program changes

troubleshoot if necessary

PUBLSTOP

Systematic approach to device follow up:

presentation

underlying rhythm

battery status

lead status

sensing

threshold

observations, data, and events

program and print

P: Presentation

presenting rhythm

percent paced

programmed parameters

presenting problems

pop-ups and alerts

Presenting Rhythm

rate

state of pacing

capture and sensing

indication

changes

Interrogation

percent paced: overview of device operation

parameters: help to analyze presenting rhythm

address alerts/problems first

make programming changes to protect patient

run tests

U: Underlying Rhythm

only need to run if device if pacing

requires temporary parameter changes

often run with sensing test

Underlying Rhythm Programming

DDD mode:

lower base rate to see atrial activity

extend AV delay to see ventricular activity

Switch to DDI/VVI if necessary for CHB patients

watch patients for symptoms

B: Battery Status

BOL/BOS: beginning of life/service

RRT/ERI: recommended replacement time/elective replacement indicator

guaranteed 3 months operation at max outputs

check voltage as battery nears ERI (BOS:2.8-3 V)

device estimate of longevity

EOL/EOS: end of life/service

should never reach

patient lost to follow up

Battery Status Report

estimated longevity

close to ERI?

increased patient risk:

pacemaker dependance

reliance on features turned off at ERI

may need earlier generation change

L: Lead Status

daily impedance trends

new impedance test

normal range: 300 - 1800 ohms

low: insulation break

high: conductor fracture or connection issue

higher impedance: lower current drain, longer battery life

L: Lead Status Follow Up

impedance trend is most important

change of 20-30% considered significant

call tech services if unsure

S: Sensing

sensing test

DDD mode:

lower base rate to see atrial activity

extend AV delay to see ventricular activity

Switch to DDI/VVI if necessary for CHB patients

watch patients for symptoms

Sensing Values

may change from acute to chronic, same expected values:

P waves > 2 mV

R waves > 5 mV

if values low but stable, no need for lead revision

Reprogramming Sensitivity

sensing issue in presenting rhythm/stored event

inappropriate safety margin

undersensing: increase sensitivity by lowering mV

oversensing: decrease sensitivity by raising mV

Af will have smaller signals

DO NOT PROGRAM HIGHER THAN 2.5 mV IN VENTRICLE OR 0.5 mV IN ATRIUM UNLESS THERE IS OVERSENSING

T: Threshold

minimum pacing output that consistently captures

pulse amplitude and pulse width

visualize with strength-duration curve

hold pulse-width stable and decrement voltage

find voltage just above loss of capture

use DDD mode to protect patient

Atrial Threshold

DDD Threshold Test

raise base rate

Ventricular Threshold

DDD Threshold Test

shorten AV delay

Wedensky Effect

higher threshold when increasing amplitude than when decreasing amplitude

Output Values

implant: 3.5-5V

chronic: 2:1 safety margin for voltage

not below 2V

outputs > 3V drain battery

may run tests at higher pulse width to troubleshoot high voltages

pulse width test: 3:1 safety margin

O: Observations, Data, and Events

rate histograms

pace/sense percentage

episodes

other device data

Rate Histograms

heart variability

Normal: bell curve

Chronotropic incompetence: concentrated near base rate

Pacing Percentages

how often is device pacing in each channel?

SND with normal conduction: should have low V pacing

extend AV delay or use algorithm to promote intrinsic conduction

high % RV pacing dangerous

Episodes

arrhythmias

device-related activity

Atrial fibrillation:

new onset: anticoagulation

impact of medication/treatment

AF burden/duration of episodes: rhythm control

ventricular response: rate control

possible algorithm adjustment

fully analyze stored EGMs

VT/VF: upgrade to ICD

Patients Symptoms

ask questions to determine when/why symptoms occur

may jump directly to episodes

common causes:

PMT

Tracking of atrial arrhythmia

Sinus tachycardia

Pacemaker syndrome

recommend programming changes

P: Program and Print

consult with physician before making permanent changes

Print:

tests

diagnostics

underlying/presenting rhythm

anything needed to explain programming recommendations

final report

newer programmers do not have built in printers

may use external printer

may keep all electronic records