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Rosens > 66.ICD > Flashcards

66.ICD Flashcards

1
Q

part of q are in anki - ? how to import

A
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2
Q

PM malfunction: what issues does this refer to?

A

circuitry or power of pulse generator
interfae between pacing electrode and myocardium

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3
Q

PM malfunction 3 categories

A

failure to pace
failure to sense
failure to capture

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4
Q

Failure to capture: what does this mean?

A

PM no spike to spikes not followed by stimulus induced complex
- lead disconnect/break vs exit block vs battery depletion

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5
Q

Failure to sense: what does this mean if undersensing?

A

lead displaced
inadequate endocardial cntat
lowc votlac intracardiac p waves and qrs complexes

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6
Q

Failure to sense: what does this mean if oversensing?

A

sensing extracardiac signals: myopotentials
t wave senssing

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7
Q

Inappropriate rate of PM: what can cause this?

A

battery depletion
ventriculoatrial conduction with PM mediated tachycardia
1:1 response to atrial dysrhthmias

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8
Q

Lead fracture common sites

A

site of attachment to the pulse generator or at abrupt angulations, which serve as stress points. Inadequate contact of the lead with the pulse generator can mimic a lead fracture. Occasionally, when a lead fracture is com- plete or nearly complete, a break in the catheter or its insulation can be detected on an over-penetrated posteroanterior chest radiograph

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9
Q

What is exit block?

A

(the failure of an adequate stimulus to depolarize the paced chamber) can also result in failure to pace

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10
Q

Inappropriate snesing - mc after what dx/events?

A

acute right ventricular infarction or during the progressive fibrosis that accompanies many cardiomyopathies, causing intracardiac signals to decrease in ampli- tude

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11
Q

T or F
Failure of a stimulus spike to produce a complex when it occurs during the atrial or ventric- ular refractory period does not represent failure to pace.

A

T

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12
Q

. Common medical sources of electrical inter- ference leading to undersensing

A

electrocautery, which can cause temporary pacemaker inhibition, and magnetic resonance imaging (MRI), which can alter pacemaker circuitry and result in fixed-rate or asynchronous pac- ing

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13
Q

Dx testing for PM

A

CXR - cath tip and number of leads
ecg
interrogation: battery level, lead integrity, device setting and ID intrinsic dysrhythmias

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14
Q

How to defib a patient with an PM?

A

Place the sternal defibrilla- tion pad adjacent to the sternum, at a safe distance (>10 cm) from the pulse generator. Alternatively, defibrillation electrodes can be placed in an anteroposterior configuration. All pacemakers should be inter- rogated after successful resuscitation

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15
Q

Will pacing return spontaneously after cardiac arrest?

A

not always so be ready to externally pace

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16
Q

What is an ICD?

A

CDs are placed for either pri- mary prevention of sudden cardiac death or, in patients that have had cardiac arrest, secondary prevention.

and ventricular Pm!

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17
Q

How does ICD pace and shock?

A

The right ventricular lead is used for sensing and pacing, and shocks are typically delivered between a coil in the right ventricular lead and the pulse generator.

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18
Q

Name 6 indications for ICD

A
  1. ischemic heart disease or SCD resulting in VF/VT - survival >1y
  2. ischemic heart dis and unexplained syncope with MMVT sustained and survival >1y
  3. depressed LVF at least 40d post MI and 90d post revasc and persistent HF sx expected living .1y
    4.Nonsustained VT due to prior MI with decr LVEF and inducible vt/vf during ep, surivla exp >1y
  4. NICM, LVEV with survival expected >1y
  5. SC arrest or sust VT from: nonischemic cardiomyopathy, arrhythmogenic right ventricular dys- plasia, hypertrophic cardiomyopathy, cardiac sarcoidosis, neuromuscular disorders, cardiac channelopathies, high-risk patients with symptomatic long QT syndrome failing beta-blocker therapy, catecholaminergic poly- morphic ventricular tachycardia failing beta-blocker therapy, Brugada syndrome, early repolarization, short QT syndrome, idiopathic polymorphic ventricular tachycardia, congenital heart disease
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19
Q

Name 8 diseases in which sudden cardiac death or sustained Ventr arrhthimas may warrant ICD

A

nonischemic cardiomyopathy, arrhythmogenic right ventricular dys- plasia, hypertrophic cardiomyopathy, cardiac sarcoidosis, neuromuscular disorders, cardiac channelopathies, high-risk patients with symptomatic long QT syndrome failing beta-blocker therapy, catecholaminergic poly- morphic ventricular tachycardia failing beta-blocker therapy, Brugada syndrome, early repolarization, short QT syndrome, idiopathic polymorphic ventricular tachycardia, congenital heart disease

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20
Q

Who gets a CRT-D?

A

decr LVEG and wide QRS
(ie biventr pacing can shock)

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21
Q

How many shocks can ICD give total?

A

6

22
Q

Name 6 sx of an ICD malfunction

A

Increase or abrupt change in shock frequency
* IncreasedfrequencyofVForVT(considerischemia,electrolytedisorder,or
drug effect)
* Displacement or break in ventricular lead
* Recurrent nonsustained VT
* Sensing and shock of supraventricular tachyarrhythmias
* Oversensing of T waves
* Sensing noncardiac signals Syncope, near-syncope, dizziness
* Recurrent VT with low shock strength (lead problem, change in defibrilla-
tion threshold)
* Hemodynamically significant supraventricular tachyarrhythmias
* Inadequate backup pacing for bradyarrhythmias (spontaneous or drug
induced)
Cardiac arrest
* Assume malfunction, but probably caused by VF that failed to respond to
programmed shock parameters

23
Q

What are mechanical ciruclatory suppor devices?

A

temporary support or LT

24
Q

NAME 4 TEMPORARY MECHANICAL circulatory support devices

A

IABP
TANDEM heart
impella
va ecmo

25
Q

IABP vs tandem heart vs impella vs va ecmo: support type

A

diastolic BP
LV
LV
biventricular

26
Q

IABP vs tandem heart vs impella vs va ecmo:
flow L/min

A

0.5
4
2.5-4
2-6

27
Q

IABP vs tandem heart vs impella vs va ecmo:
oxygenation? y/n

A

no
no
no
y

28
Q

IABP vs tandem heart vs impella vs va ecmo: common complications

A

low plt
hemolytsis,bleed, specialist RQ
“
hemolysis, bleed

29
Q

IABP vs tandem heart vs impella vs va ecmo: adv

A

fast
percut LV bypass
perc LV support
biv support

30
Q

IABP vs tandem heart vs impella vs va ecmo: type of pump

A

pneumatic
motor to axial
centrigual
heat exchange/membrane oxygenator and centrifugal pump

31
Q

Parts of a VAD

A

The pump is connected to a percutaneous driveline connected to a controller and a power source. The controller and batteries are worn by the patient on a belt and shoulder harness, allowing them to be carried (Fig. 66.10). The controller displays battery life and alarms, and may provide additional information such as power level and estimated flow

32
Q

How to assess adequate perfusion in a VAD pt?

A

Adequate per- fusion can be assessed by evaluating clinical signs, including mental status, urine output, and skin turgor, but these have obvious limita- tions. A

utomated oscillometric blood pressure cuffs may not work to measure blood pressure with LVADs because of the low pulse pressure. Blood pressure can be measured using a manual cuff and a stetho- scope or Doppler probe.

33
Q

How to get MAP in VAD pt?

A

manual cuff pressure is reduced until a con- tinuous sound is heard, which represents the systolic pressure. This is essentially equal to the mean arterial pressure because of the low pulse pressure. Blood pressure can also be measured invasively using an arterial catheter.

34
Q

VAD diagnostic tests

A

cxr
ecg
cardiac monitoring
coag studies, cbc
haptoglobin and LDH level for hemolysis

35
Q

Inadequate preload may lead to low flow/suction alarm - what does this mean?

A

decr IV vol - need to look with echo and look for hypovlemia, hemorrhage or vasodilatory source

or obstructive shock can do this

36
Q

Low afterload in VAD - what might this show?

A

increased VAD flow initially, as it becomes easier for the mechanical pump to eject blood into the aorta; however, it may lead to decreased LV volume and “suction” problems as the walls of the ventricle collapse on the VAD intake ports. This can lead to decreased flow, suction alarms, and ven- tricular dysrhythmias

37
Q

Common intracorporeal VAD alarms: no display
?problem?
?cause
?ac tion

A

power source
no power
check connections

38
Q

Common intracorporeal VAD alarms: suction
?problem?
?cause
?ac tion

A

low preload or afterload
hypovol/hemorrhage/RV fail/rhythm/vasodil

39
Q

Common intracorporeal VAD alarms: low flow
?problem?
?cause
?ac tion

A

high bp or low bp
high afterload if high bp vs low: hypovol, hemorrhage, RV fail, rhythm

If high afterload: antiHTN
vs low: IVF/blood products, eval for sepsis

40
Q

Common intracorporeal VAD alarms: high power
?problem?
?cause
?ac tion

A

pump R
thrombosis/high BP
eval for hemolysis/anticoag

41
Q

Common intracorporeal VAD alarms: low battery
?problem?
?cause
?ac tion

A

low battery
low battery reserve
replace battery or plug into power source

42
Q

Goal MAP for VAD pt

A

typically >/=65

43
Q

Why are bleeding complications common in VAD pt?

A

Need anticoag (check taking it)
development AVM due to nonpulsatile flow
acquired coagulopathies due to device

REVERSAL is last resort as need this not to clot!!

44
Q

Thrombotic complications of VAD

A

cva
intestinal ischemia

tx with systemic anticoag

45
Q

Preload problem in VAD - how to fix?

A

fluids, blood etc
if still low - NE

46
Q

Which of the following conditions is an indication for placement of a biventricular pacemaker?
a. Third-degreeAVblock
b. Brugada syndrome
c. Severely depressed systolic heart failure and a left bundle branch block
d. Slow atrial fibrillation

A

c

47
Q

A 67-year-old female presents with complaints of shortness of breath and a fluttering sensation in her chest. She had a dual- chamber pacemaker placed 10 years ago for sinus node dysfunc- tion. Blood pressure is 124/96 mm Hg. On examination, she is anxious with clear lungs and no evidence of jugular venous distention or peripheral edema. There is no tenderness over her pacemaker insertion site. An ECG is provided as follows.
Which of the following is the next best step in the management of this patient? (odd pacer spike)
a. Administration of IV amiodarone
b. Drawing blood cultures and starting antibiotics
c. Immediatecardioversion
d. Placement of a magnet over the pacemaker

A

d

48
Q

A 67-year-old male with a history of an ischemic cardiomyopathy and an implantable cardiac defibrillator (ICD) presents with com- plaints of multiple shocks from his ICD in the past day. Interro- gation of his ICD shows no evidence of any shocks in the past 2 months. What is the most appropriate management plan?
a. Administration of intravenous amiodarone
b. Cardiology consultation for reprogramming of ICD
c. Reassurance and follow-up with his cardiologist
d. Temporary ICD deactivation with magnet application

A

c

49
Q

A 55-year-old man presents with chest pain and hypotension. ECG reveals ST-elevation MI in the inferior and lateral leads, and bedside echocardiogram shows poor systolic function of both ventricles. He has elevated jugular venous pressure, and a ple- thoric IVC on ultrasound. In addition to percutaneous coronary interventions, which of the following therapies would be most appropriate to consider?
a. Intra-aorticballoonpump
b. Temporary LVAD (e.g., Impella or Tandem Heart)
c. Veno-venousECMO
d. Veno-arterial ECMO

A

d

50
Q

A 65-year-old man with an intracorporeal left ventricular assist device (LVAD) presents to the emergency department and tells you he has felt lethargic for the past two days. A manual blood pressure cuff and Doppler ultrasound show a systolic blood pres- sure of 75 mm Hg, and a continuous “hum” is heard on ausculta- tion. The cardiac monitor shows a wide complex tachycardia, and no pulse is palpable. Which is the most appropriate next step in management?
a. Administeramiodarone b. Begin chest compressions
c. Call heart failure specialist and continue diagnostic evaluation
d. Immediate cardioversion/defibrillation

A

c

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