ICDs, Ablations, IR Anesthesia

Question 1

Biventricular PPM

Answer 1

-Has 3 leads placed. RA + RV + LV
-LV placed via coronary sinus that can be tricky and takes time to access during surgery

Question 2

Reed Switch

Answer 2

Synchronous to asynchronous w/ magnet placement
-2 metal strips that connect w/ magnet
-Inactivates sensing circuit

Question 3

Bipolar PPM & ECG

Answer 3

Smaller pacer spiked on ECG d/t less EMI interference d/t less distance needed to travel

Question 4

ERI

Answer 4

Electronic Replacement Indicator = Generator change

Question 5

Why PPM often placed LEFT side

Answer 5

Most people are right-handed to place on left side bc less likely to have lead displacement

**Caution Left side placement d/t thoracic duct being on Left side

-Arms are tucked during PPM

Question 6

Single chamber pacemaker

Answer 6

One lead that can be atrial or ventricular
-May see switching of pacer spikes on ECG

*May need to increase rate or milliamps to override

Question 7

Dual chamber DDD

Answer 7

DDD 60-120 thresholds

Question 8

Asynchronous mode

Answer 8

Paced independent of heart’s intrinsic rate = override intrinsic rate

Question 9

Threshold

Answer 9

Minimal electrical output needed to CONSISTENTLY contract or capture (atrial or ventricular or both)

*Turn down mA slowly until capture lost (around 0.7-1.0 mA). Then slowly turn up mA until capture.
**Then set mA 2x threshold

Question 10

Failure to capture

Answer 10

PPM output does NOT cause myocardial depolarization

Question 11

Failure to sense

Answer 11

Failure of PPM to recognize intrinsic cardiac electrical activity

Question 12

What is the single most important risk factor for overall mortality & sudden cardiac death?

Answer 12

Reduced left ventricular ejection fraction

Question 13

Brugada syndrome is an indication for …..

Answer 13

ICD

Question 14

Brugada Syndrome

Answer 14

*RBBB w/ ST elevation in R precordial leads (V1-V3)
-Caused by mutation in voltage gated sodium channels. Males > females.
-3 types = coved + saddle back w/ ST elevation >/< 2mm
-Syncope, dizzy, palpitations

Question 15

How many codes do a PPM & an ICD have

Answer 15

PPM = 5 codes
ICD = 4 codes

Question 16

ICD joules for V-fib

Answer 16

10-30 joules. Starts higher than ventricular tachycardia shock

Question 17

Why is it important to have ICD interrogated before & after surgery?

Answer 17

Prevents from not having enough juice to shock & get out of lethal rhythm if needed intraoperatively

Question 18

What is needed with ICD if monopolar cautery used?

Answer 18

Grounding pad

Question 19

If see shock coils on CXR

Answer 19

Safe to assume ICD

Question 20

Stimulating parts of CIED placement requiring higher level of anesthesia

Answer 20

-Local injection
-Pocket formation

Question 21

Cautery & CIEDs increase

Answer 21

airway fire risk of 3

-Common gas outlet (CGO) blend of 3/1 = fiO2 or ~30%

Question 22

3 Important points of anesthesia for AICD

Answer 22

-Pts can be less healthy w/ decreased EF
***Watch circulation time & drug effects = etomidate, propidate, prop gtt all work well
-Transcutaneous pads on & functional incase internal device failure with DFT test

Question 23

CIED

Answer 23

Cardiac implantable electronic device

Question 24

CIED & monopolar cautery, important to have what ready as an anesthetist?

Answer 24

-Chronotropic meds & emergency pacing if pacer dependent
-Ephedrine, atropine, EPI, dopa

-Use short burst <5sec to ensure no device interference detection

Question 25

Medtronic PPM/ICD Magnet Summary

Answer 25

*ICD inhibited until magnet removed. High-low tone indicates device malfunction
BOL = 85
ERI = 65
-Binary change
-Yes program

Question 26

Biotronik PPM/ICD Magnet Summary

Answer 26

*ICD inhibited until magnet removed
BOL = 90 asynchronous
ERI = 80
-Binary change
-Yes program

Question 27

Boston Scientific PPM/ICD magnet Summary

Answer 27

*ICD inhibited until magnet removed
*Synchronous Pace w/ beeping tone on R-wave or every sec
BOL = 100
ERI = 85
-Gradual change
-Yes program

Question 28

Where do 90% + of foci contribute to A-fib?

Answer 28

Pulmonary veins in area of LV

Question 29

SA node can contract how fast with A-fib

Answer 29

400-600x /min
-AV node = traffic controller to prevent 400-600 impulses traveling to ventricles through Purkinje network

Question 30

Atrial flutter is confined to ________?

Answer 30

Right atrium of heart.
-Atria can beat 200-400 bpm
-Commonly seen after heart surgery or any type of dilation or abnormality of right heart