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Year 3 - Cardiac Rhythm Management > CRM13: CRT > Flashcards

CRM13: CRT Flashcards

1
Q

What is heart failure?

A

-Complex, progressive disorder in which heart function is reduced
-Heart muscles either becomes stiff or dilated

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2
Q

What are the 2 types of heart failure?

A

HFpEF - diastolic dysfunction
HFrEF - systolic dysfunction

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3
Q

Symptoms of heart failure

A

-SOB
-Fluid retention
-Fatigue
-Cough

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4
Q

Causes of HF

A

-IHD
-Valvular disease
-Hypertension
-HCM
-DCM

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5
Q

What does electrical dyssynchrony look like on ECG?

A

LBBB
-Left and right ventricle are not pumping in synchrony

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6
Q

Risks of directly stimulating the LV

A

-Higher pressure in the left ventricle
-Clots

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6
Q

How is LV stimulation achieved?

A

-Placing a pacing lead in a branch of the coronary sinus

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7
Q

Difference between CRT-P and CRT-D

A

-CRT-D has shocking lead which goes into right ventricle (thick)

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8
Q

NICE guidelines for ICD and CRT implant based on NYHA class and QRS interval

A
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9
Q

Features of coronary sinus leads

A

-Coronary sinus leads are flexible to negotiate venous system
-Variety of shapes available for selected veins
-Majority do not have fixation as friction of vessel walls holds them in place
-IS-4 leads have 4 poles to pace from and can cover different vectors within ventricle

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10
Q

Which area of heart is best for achieving effective CRT?

A

-Posterolateral

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11
Q

Is basal or apical activation better in CRT?

A

Basal

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12
Q

Risk of going for coronary sinus in CRT?

A

-AV node can be disturbed
-Patients with BBB could get complete heart block

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13
Q

Which cardiac veins are most commonly gone for in CRT to target left ventricle?

A

-Lateral cardiac vein
-Postero-lateral cardiac vein

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14
Q

Why should there be a distance between left and right leads?

A

-To activate the largest area possible

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15
Q

Process of CRT implantation

A

-Venous access
-Place atrial and RV leads - test
-Use delivery catheter to intubate coronary sinus
-Perform venogram
-Select vein and lead shape
-Place lead
-Measure threshold and QLV
-Test of phrenic nerve stimulation

16
Q

Threshold and impedance ranges in CRT

A

-High thresholds and impedance are acceptable, especially with limited suitable veins
-Threshold 2.0V @ 0.4ms
-Impedance 300-1300ohms

17
Q

Phrenic nerve stimulation in CRT

A

-Phrenic nerve stimulation is tested at 5V and 10V
-Don’t want to cause phrenic nerve stimulation when pacing ventricle
-Place hand on stomach to see if twitching
-No fixation to vessel so leads may move

18
Q

What is QLV interval?

A

-Measurement from onset of QRS of surface ECG to first positive or negative peak of LV electrogram (EGM)
-Indicates dyssynchrony and the latest area of deactivation
-QLV>95ms is good indication of resynchronisation

19
Q

Issues with pacing in scar tissue

A

-Substrate for arrhythmias
-Delayed conduction

20
Q

Features of lead testing in CRT

A

-Multiple vector testing
-Ideal vector should be as basal as possible
-Threshold should be low
-Higher impedances can reduce current drain on battery however need for balance
-Can have unipolar pacing vectors
-Assess ECG changes during testing (Look at V1 for LBBB and RBBB)

21
Q

Complications of CRT implant

A

-CS lead displacement
-Asystole during CS cannulation
-CS dissection
-CS lead leading to arrhythmia
-High thresholds (battery drain)
-Phrenic nerve stimulation
-Long procedure time = increased risk of infection

22
Q

Why does RV lead go in first?

A

-RV lead goes in first so you can pace if left lead causes arrhythmia

23
Q

Benefits of conduction system pacing?

A

-Preservation of native activation
-Better results
-More stable lead positions
-Does not depend on venous anatomy
-Pacing along conduction system avoids cardiac remodelling

24
Q

What is WISE CRT?

A

Wireless Stimulation Endocardially:
-Delivers ultrasonic energy to LV endocardial receiver to achieve biventricular pacing
-Potential solution to patients who failed conventional CRT
-Percutaneously delivered LV endocardial electrode delivers electrical stimulus that is synchronised to RV pacing output

25
Q

CRT follow up

A

-6/12 month follow up
-Effective CRT Biventricular pacing percentage (>95%)
-Causes of reduced BiVp - lead malfunction, arrhythmia, ectopics
-Assess lead measurements
-Heart rate histograms - maintain BiVp at higher rates and rates not going too fast
-Patient symptoms - HF symptoms?
-Optimisation of ECG - narrowest ECG possible

26
Q

What device should patient get?

A

CRT-D
-NYHA 3
-LBBB with prolonged QRS

27
Q

Why were the sensing values lower at implant?

A

-Dilated ventricle
-Ischaemia (scarring)

28
Q

What has happened?

A

-LV lead has displaced
-Not capturing
-Needs to be repositioned
-Patient still has LBBB

Year 3 - Cardiac Rhythm Management (10 decks)

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