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I&M II > III. Cardiac Support Devices > Flashcards

III. Cardiac Support Devices Flashcards

1
Q

3 different implantable devices

A
  1. Implantable Permanent Pacemaker
  2. Implantable Cardioverter Defibrillator
  3. Intra-aortic Balloon Pump
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2
Q

Implantable Permanent Pacemaker is for
Treatment of ____

A

bradycardia

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3
Q

Implantable Cardioverter Defibrillator
is for treatment of ____.

A

tachycardia and fibrillation

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4
Q

Intra-aortic balloon pump is for treatment of
____.

A

Left ventricular support

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5
Q

PM of today

____ lead placement

A

Transvenous

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6
Q

Goals of pacemakers today

A

A satisfactory heart rate to maintain effective cardiac output
A chrono-tropic physiological response
Atrio-ventricular synchronization
Inter-ventricular and intra-ventricular synchronization
Treat or prevent arrhythmias

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7
Q

routes of temporary pacing

A

transvenous, transcutaneous/transthoracicesophageal

NOT trans-arterial

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8
Q

indications for temporary pacing

A

Unstable Brady-dysrhythmias
Atria-ventricular heart block
Unstable tachydys-rhythmias

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9
Q

temporary pacing

Endpoint is reached after:

A

a resolution of reversible problem or permanent pacemaker implantation.

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10
Q

Indications for Permanent Pacemaker

A
  • Sick sinus syndrome
  • Tachy-brady syndrome
  • Symptomatic sinus bradycardia
  • A-fib with slow ventricular response
  • 3rd degree heart block
  • Chronotropic incompetence (Inability to increase heart rate to match exercise)
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11
Q

Permanent Pacemaker Indications

Non-indications

A
  • Syncope of undetermined etiology
  • Asymptomatic sinus bradycardia
  • Asymptomatic 1° & 2° Mobitz Type 1 AV Block
  • Reversible AV block
  • Long QT syndrome or Torsades de pointes due to a reversible cause
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12
Q

Computerized device taht regulates the timing and sequence of one’s heartbeat

A

pacemaker

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13
Q

Pacemaker Basics

Detect the ____ activity (sense)

A

intrinsic

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14
Q

pacemaker system components

A
  • pulse generator
  • lead/s (encased in silicone)
  • Programmer
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15
Q

benefits of lithium-diode battery (power source)

A
  • 5-15 yr life
  • voltage decrease gradually
  • sudden failure UNLIKELY
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16
Q

battery placement

A

under submuscular plane of the pectoralis major

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17
Q

computer component of PM?

A

pulse generator

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18
Q

3 functions of PM circuitry

A
  1. time
  2. sensing
  3. output
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19
Q

pacemaker sizes pic

A

today we use <30cc

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20
Q

Leads placed via central access & fixed to ____.

A

endocardium of RV or RA

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21
Q

Distal attachment methods:

A

Active fixation → metal screw-in
Passive fixation → rubber fins/wingtips or tines

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22
Q

Pacing Leads Variety Pic

A
"Sensing" abilities are similar
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23
Q

____ fixation has porous carbon for improved contact and decreased pacing thresholds.

A

passive

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24
Q

Pacemaker Implant Pic

A
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25
Q

3 locations of PM access

A
  • R/L subclavian vein
  • cephalic vein
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26
Q

Pacing & Depolarization of Myocardial Tissue

The myocardium must be ____ (not in refractory period)

A

excitable

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27
Q

Pacing & Depolarization of Myocardial Tissue

The stimulus current density (current per cross-sectional area) must:
1. Must be sufficiently ____
2. Sufficient ____
3. Lead in good position & with ____ with myocardium

A

high
duration
sufficient contact

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28
Q

Pacing & Depolarization of Myocardial Tissue

The pacemaker-generated impulse then relies on the ____ properties of the cardiac specialized conduction & myocardial tissue for depolarization of the entire heart (aka: ____)

A

intrinsic

AKA: “capture”

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29
Q

Sensing

Sensing is the detection of ____.

A

real or spontaneous cardiac depolarization

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30
Q

Factors that affect sensing:

A
  • Electrode size
  • Configuration of electrode
  • Position of the lead tip within the heart and contact to the myocardium
  • Programmed sensitivity level
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31
Q

Types of Pacemakers

A

Unipolar vs. Bipolar vs. Multipolar

Single vs. Dual Chamber vs. Multisite

Asynchronous vs. Synchronous

Programmable vs. Non-programmable

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32
Q

Polarity of the Pacemaker System

Unipolar → ____
Bipolar → ____
Multipolar → ____

A

Unipolar →** highest sensitivity for sensing**
Bipolar →** improved rejection for more reliable sensing**
Multipolar → special purpose leads

Quadripolar → Targeted cardiac resynchronization.

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33
Q

Unipolar Pacemaker Circuit

Larger “antenna” for sensing → Bigger signals, but more ____

A

interference

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34
Q

Unipolar Pacemaker Circuit

Large circuit (____ cm) b/t single electrode at distal end of lead and the pulse generator

A

± 40-60cm

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35
Q

Unipolar Pacemaker Circuit

____ unipolar → cases where AV conduction is likely to return.
____ unipolar → normal AV conduction w/ SA node disorder.

A

Ventricular
Right atrium

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36
Q

Unipolar Pacemaker Circuit

Advantages:

A

High sensitivity for sensing
Large pacemaker spikes on ECG (easy interpretation)

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37
Q

Unipolar Pacemaker Circuit

Disadvantages:

A

Extracardiac stimulation possible (pectoral pocket muscle)
Sensing of extracardiac signals (i.e. detecting ventricular depolarization from atrial lead)
Non-physiological interference

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38
Q

Bipolar Pacemaker Circuit

Short circuit (____mm) between 2 electrodes at the distal end of the lead

A

± 10-15

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39
Q

Bipolar Pacemaker Circuit

Advantages:

A

Improved rejection of extra-cardiac and/or non-physiologic stimulation = More reliable sensing

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40
Q

Bipolar Pacemaker Circuit

Disadvantages:

A

Small pacemaker spikes (difficult interpretation of pacemaker ECG)

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41
Q

____ pacing (i.e. AAI)
Limited indications in pts. with SSS and intact conduction system or for anti-tachycardia purposes

A

Single chamber atrial

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42
Q

Single chamber ventricular pacing (i.e. VVI):
Less expensive; non-physiological loss of AV synchrony; loss of around ____% CO

A

25

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43
Q

Single Chamber Pacemakers

Preferred only in chronic atrial fibrillation and heart block, or those with very limited activity

A

Single chamber ventricular pacing (i.e. VVI):

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43
Q

Single chamber ventricular pacing (i.e. VVI):

____% incidence of pacemaker syndrome

A

15

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44
Q

“Sequential” pacemaker = electrodes in RA and RV → allows AV synchrony

A

Dual Chamber Pacemakers

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45
Q

Allows physiological variability of pacing rate

A

Dual Chamber Pacemakers

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46
Q

Dual Chamber Pacemakers

Advantages:
Increase/decrease of the cardiac output
Improved ____
No ____ syndrome [TQ]

A

Increase
Quality of Life
Pacemaker

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47
Q

Dual Chamber Pacemakers

Disadvantages:

A

Expensive & complex
V-V dys-synchrony possible
Inter-channel interferences possible

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48
Q

Multi-site Pacemakers: Dual Site Atrial Pacing

Leads placed at:
Atrial leads ____, other in the ____
Ventricular lead in the ____ at the apex or outflow tract.

A

RA appendage
coronary sinus
RV

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49
Q

Biventricular pacemakers

Leads placed at: ____, ____, ____

A

RA, RV, & LV

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50
Q

Biventricular pacemakers

Useful in the management of patients with heart failure who have evidence of ____ & ____

A

abnormal intraventricular conduction (i.e. LBBB)
V-V dys-synchrony.

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51
Q

Fixed Rate (Asynchronous) Modes:

AOO →
VOO →
DOO →

A

Fixed rate atrial pacing (asynchronous)
Fixed rate ventricular pacing (asynchronous)
Fixed rate AV sequential pacing (asynchronous to intrinsic rhythm)

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52
Q

Fixed Rate (Asynchronous) Modes

T/F: Impulse produced at a set rate with no relation to patients intrinsic cardiac activity.

A

true

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53
Q

Synchronous Pacing

Can mimic ____ pattern of the heart

A

intrinsic electrical activity

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54
Q

Pacemaker Codes & Modes

1st letter →

A

chamber Paced

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55
Q

Pacemaker Codes & Modes

2nd letter →

A

chamber Sensed

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56
Q

Pacemaker Codes & Modes

3rd letter →

A

Response to chamber sensed

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57
Q

Pacemaker Codes & Modes

4th letter →

A

Programmable features

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58
Q

Pacemaker Codes & Modes

5th letter →

A

Anti-tachycardia response

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59
Q

Pacemaker Codes & Modes Table Pic

A
60
Q

Response to sensing options (3)

A

I (inhibited) → Withhold a pacemaker output in response to a sensed event.

T (triggered) → Produces output spikes coincident with the sensed signal.

D (dual) → I and/or T

61
Q

4th - Programmable Options

A

O (none) → not programmable
P (simple programmable) → limited to 3 or fewer programmable parameters
M (multiprogrammable) → device can be programmed in more than 3 parameters
Rate, sensing, output, refractory periods, mode, hysteresis
C (communicating) → capable of transmitting or receiving data for informational or programming purposes.
R (rate responsive) → device is capable of a rate responsive function

62
Q

Most bradycardia devices are what (4th) programmable option

A

O (none)

63
Q

5th — Anti-tachycardia Responses (4)

A

O (none) → Not activated

P (paced) → pace the patient out of tachycardia

S (shocks) → deliver a defibrillating shock

D (dual) → paced and shocks (MOST ICDs)

64
Q
  • Fixed rate ventricular pacing (no sensing or response)
  • Asynchronous pacing
  • Indications:
    Temporary mode sometimes used during surgery to prevent interference from electrocautery.
  • Monitor for R on T with ESU diathermy → torsades de pointes
A

VOO

65
Q
  • Ventricular pacing and sensing
    If no intrinsic electrical impulse sensed → paced at a pre-set rate
    If intrinsic electrical impulse sensed → pacing inhibited
  • Asynchronous pacing
  • Indications: Combination of high grade AV block and chronic atrial arrhythmias (particularly A-fib)
  • VVIR = as above but adds rate-adaptive mechanism for exercise
A

VVI

66
Q
  • Paces + Senses both atrium and ventricle
  • If no intrinsic electrical impulse sensed → triggers pacing (EKG – 2 spikes)
  • If intrinsic electrical impulse sensed → pacing inhibited
  • AV Synchronicity maintained (“Sequential”)
A

DDD

67
Q

DDD

Indications:

A

Combination of AV block and SSS
Pts. w/ LV dysfunction and LV hypertrophy who need coordination of A & V contraction to maintain adequate CO

68
Q

DDD

adds rate-adaptive mechanism for exercise

A

DDDR

69
Q

Atrium paced, Atrium sensed, & will inhibit if intrinsic electrical impulse
AV Synchrony maintained

A

AAI

70
Q

AAI

Indications

A

Sick sinus syndrome in the absence of AV node dz. or A-fib.

71
Q
A

Failure to Capture

72
Q
A

Ventricular Pacemaker

73
Q

Rate responsive pacing is influenced by what three variables

A
  1. activity sensors (accelerometers)
  2. Motion
  3. Ventilation
74
Q

Pacemaker complications apperent on EKG:

A
  1. Failure to Output
  2. Failure to Capture
  3. Sensing Abnormalities
75
Q

what is occuring?

A

failure to sense

76
Q

what is occuring

A
77
Q

Pacemaker Syndrome

Low CO and heart failure like manifestations that happens in about 15% of pts with VVI or VOO pacemakers as a result of _____.

A

loss of AV synchrony.

78
Q

pacemaker syndrome

Atria contract against closed valves = ____ waves

A

(cannon A waves)

79
Q

Pacemaker Syndrome

Symptoms:

A

Vertigo/Syncope (worsens with exercise)
Unusual fatigue
HoTN
Cyanosis
Jugular vein distention
Oliguria
Dyspnea/SOB
Altered mental status

80
Q

Pacemaker Syndrome

Treatment:

A

establish normal AV synchrony

81
Q

Pacemaker Syndrome EKG Pic

A
82
Q
  • Designed to treat a cardiac tachydysrhythmia
  • Performs cardioversion/defibrillation
  • ATP (antitachycardia pacing)
  • Some have pacemaker function (combo devices)
A

Automatic Implantable Cardio-Defibrillator (AICD or ICD)

83
Q

Biventricular pacemakers that are combined with an implantable cardioverter defibrillator (ICD) do not tend to last as long — ____ years

A

about two to four years.

84
Q

AICD Functions

A

Antitachycardia Pacing
Cardioversion
Defibrillation
Bradycardia Pacing

85
Q
  • Generally used in patient’s who experienced a previous cardiac arrest
  • Patients with undetermined origin of, or continued, VT or VF despite medical interventions
A

AICD

86
Q

Antitachycardia Pacing Pic

A
87
Q

ICD Cardioversion Pic

A
88
Q

ICD Defibrillation Pic

A
89
Q

____ delivers an asynchronous shock of energy.

A

Defibrillation

90
Q

____ delivers a reduced shock of energy in synchrony with QRS complex.

A

Cardioversion

91
Q

What type of PM shock is delivered if patient is in V-Fib?

A

ICD Defibrillation,

Once out of V-Fib, PM will pace asynchronously (VVI mode) until the device is reset by healthcare provider

92
Q

A magnet placed over the pacemaker does what?

A
  • converts to asynchronous mode (will not sense/defibrillate/cardiovert)
93
Q

If a magnet is placed over the heart, and the PM is disabled, what function does the PM retain?

A

ability to pace

94
Q

A procedure above what level should present some concern for PM interference?

A

umbilicus

95
Q

Using a magnet to disable the PM is appropriate for a/an ____ procedure.

A

emergent

if procedure is non-emergent, a rep will disable in pre-op

96
Q

What is convenient about using Neo in conjuction with PM patients?

A

No reflex bradycardia

97
Q

Steps to take if patient with AICD codes:

A

1. Start CPR & Defibrillate

98
Q

T/F: If pt with AICD codes, removing the magnet is a reliable method of defibrillating patient.

A

FALSE

magnet ‘likely’ deprogrammed AICD, now requires provider to reset

99
Q

Person giving CPR may feel slight buzz if AICD functions
A 30-joule intra-cardiac shock is ____ j on skin

A

<2 J

100
Q

Coding pt with AICD

Change paddle placement if unsuccessful attempt:
Try ____ paddle placement if Anterior-Lateral unsuccessful.

A

Anterior-Posterior

101
Q

External defibrillation will/will not not harm AICD

A

will not

102
Q

A counterpulsation system that is used to give temporary support to the LV by mechanically displacing the blood w/i the aorta.

A

Intra Aortic Balloon Pump (IABP)

one of the most common modalities of augmenting circulatory support

103
Q

How does the IABP work?

A

It optimally times inflation and deflation contractions of the heart

104
Q

What are the advantages of using a IABP?

A
  1. ↓LV systolic work, LVEDP & Wall Tension
  2. ↓O2 consumption
  3. ↑CO, Pefusion, CPP (Coronaries)
105
Q

What patients most often require a IABP?

A

HF and/or cardiogenic shock

106
Q

IABP Placement

A flexible catheter with long balloon mounted on the end → inserted via ____ → placed in ____

A

femoral artery
descending aorta

107
Q

IABP

Balloon is inflated to displace blood in ____(“counter pulsation”)
When inflated, balloon blocks ____

A

aorta
85-90% of aorta.

108
Q

IABP

Sudden inflation = moves blood ____ and ____ to balloon (inc. pressure).

A

superiorly
inferiorly

109
Q

IABP

when does the IABP balloon inflate?

A

immediately after aortic valve closure (during diastole)

after LV contraction ejected blood through aortic valve into aorta; but heart is weak and is unable to contract hard enough to circulate blood effetively. That is why the balloon pump then inflates, forcing blood superiorly, into coronary arteries, and inferiorly to distal organs.

110
Q

IABP

What is caused by balloon inflation?

A
  1. ↑ aortic pressure
  2. ↑ Coronary Perfusion Pressure & BF
  3. ↑ Systemic Perfusion Pressure
  4. ↑ O2 supply to both the coronary and peripheral tissue
  5. ↑ Baroreceptor Response
  6. ↓ Sympathetic Function = ↓HR, ↓SVR, ↑LV Function
111
Q

The balloon remains inflated throughout the entirety of what part of cardiac cycle?

A

diastole

112
Q

IABP

Triggered to deflate during:

A

opening of the aortic valve (onset of systole)

to allow blood volume to enter aorta, so that it may be soon pumped out

113
Q

IABP

Deflation creates a “____” in the aorta (↓volume and ↓pressure) = reduced impedance to ____.

A

potential space
LV ejection

114
Q

IABP

What are the cardiac effects of deflating balloon?

A
  1. ↓afterload → ↓ myocardial oxygen consumption (MVO2)
  2. ↓peak systolic pressure → ↓LV work.
  3. ↑CO
  4. ↑EF & forward flow
    (Normal EF = 50-70%)
115
Q

IABP Hemodynamic Effects Table Picture

A
116
Q

Indications for IABP

A
  • Refractory unstable angina (despite maximal medical management)
  • Persistent myocardial ischemia
  • Cardiogenic shock
  • Acute mitral regurgitation
  • Perioperative treatment of complications due to myocardial infarction
  • Failed PTCA (Percutaneous transluminal coronary angioplasty)
  • As a bridge to cardiac transplantation
    (15-30% of end-stage cardiomyopathy pts. awaiting transplantation need mechanical support.)
  • During or after cardiac surgery
    (Cardiac failure / weaning from CPB)
116
Q

IABP

Contraindications

A
  • Severe aortic insufficiency
  • Aortic aneurysm
  • Aortic dissection
  • Limb ischemia
  • Thromboembolism
  • Uncontrolled sepsis
  • Severe PVD
  • End-stage heart dz. with no anticipation of recovery.
117
Q

IABP Components Picture

A
118
Q

list IABP 2 major components

A
  1. Double-Lumen catheter w/ balloon
  2. Console w/ pump to drive the balloon
119
Q

size of IABP catheter

A

7.5-9.5 Fr

120
Q

IABP

IABP balloon capacity

A

30-60 mL

121
Q

how is the IABP sized?

A

based on pt height

122
Q

How many lumens does the catheter have?

A

2

  • gas exchange (blowing up balloon)
  • monitoring central aortic pressure
123
Q

2 different gases used to inflate balloon

A
  1. helium
  2. CO2
124
Q

Helium vs CO2

Pros & Cons

A

Helium:
- lower density, inflates/deflates faster
- risk of air embolism if balloon rupture

CO2:
- Safer, dissolves into blood quickly
- slower balloon response

125
Q

What does radio opaque marker on IABP allow for?

A

placement confirmation on X-ray

126
Q

The end of the balloon should be just distal to the takeoff of the ____.

A

left subclavian artery.

Tip approximately 1-2cm below the origin of the left subclavian artery and above the renal arteries.

127
Q

Position should be confirmed by ____ or ____.

A

fluoroscopy
chest x-ray

Should be visible in the 2nd or 3rd intercostal space

128
Q

Event the pump uses to identify the onset of cardiac cycle (systole)

A

Trigger

129
Q

most common modality used as trigger for IABP

A

ECG

130
Q

On ECG:

Inflation occurs at ____.
Deflation occurs at ____.

A

Inflation: end of T-wave

Deflation: beginning of R-wave

131
Q

If arterial pressure waveform is used as IABP trigger,

Inflation occurs at: ____

Deflation occurs at: ____

A

Inflation: dicrotic notch

Deflation: systolic upstroke

132
Q

What modality is used by IABP during CPB or VFib?

A

intrinsic set rate

(1:1 - 1:8)
every beat or every 8th beat

133
Q

Normal augmented A-line Waveform with IABP

A
134
Q

Will MAP decrease or increase with a IABP?

A

Increase

Although systolic pressures decrease slightly, diastolic pressure increases significantly.

135
Q

Diastolic augmentation should be lower/higher than systolic.

A

higher

136
Q

Early Inflation (before dicrotic notch)

…if balloon inflates too soon, interrupting the end of systole

A
  • Increase work of heart (at end systole)
  • Aortic Regurgitation (inflation will cause backflow of blood into LV)
  • 2nd worst
137
Q

Late Inflation (after dicrotic notch)

A
  • Heart is not getting enough help during diastole
  • decreased Coronary Perfusion
  • NOT making heart work, just less effective
138
Q

Early Deflation

…while heart is still in diastole

A
  • some help with coronary perfusion, just not optimal
  • not making the heart work harder
138
Q

Late Deflation

A
  • WORST
  • balloon obstructing systole
  • Significantly Increases work of heart
139
Q

IABP Complications

A
  • Limb ischemia
    (Thrombosis, Emboli)
  • Local vascular injury
    (Bleeding at insertion site, Groin hematoma, False aneurysm)
  • Aortic perforation and/or dissection
  • Malpositioning causing cerebral, renal, or bowel compromise
  • Neurologic complications including paraplegia
  • **Heparin induced thrombocytopenia
  • Balloon rupture → gas embolus
    Infection**
140
Q

Weaning from IABP

A
  • Timing of weaning
    (Patient should be stable for 24-48 hours)
  • Decreasing inotropic support
  • Decrease augmentation slowly
  • Decreasing pump ratio
    (From 1:1 to 1:2 or 1:3)
  • Monitor patient closely
    (If patient becomes unstable, weaning should be immediately discontinued)
141
Q

Final Points IABP

The primary goal of IABP treatment is to increase ____ and decrease ____.

A

myocardial O2 supply
myocardial O2 demand

142
Q

Final Points IABP

Decreased urine output after insertion may occur because of balloon positioning obstructing ____.

A

renal artery

143
Q

Hemolysis from mechanical damage to RBCs can reduce Hct by up to ____%

A

5%

144
Q

IABP is ___-genic → always anticoagulant the pt.

A

thrombo

145
Q

Final Points IABP

T/F: Never switch the balloon off while in use

A

True

I&M II (7 decks)

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