Your Patient has a CIED (Cardiac Implantable Electronic Device): Now What? Laurie Racenet, FNP, MSN, CCDS, CEPS, FHRS Alaska Heart and Vascular Institute

Types of Devices Pacemakers Single Dual BiV (CRT) Leadless ICDs S-ICD (sub Q implant) Loop Recorders

What Functions do the devices perform? Pacemakers Pace the heart to prevent bradycardia Can increase heart rate with activity Records diagnostic information about the patient Some devices can deliver anti-tachycardia pacing for atrial arrhythmias only

What Functions do the devices perform? ICDs Pace the heart to prevent bradycardia Can increase heart rate with activity Records diagnostic information about the patient Deliver anti-tachycardia pacing for atrial and ventricular arrhythmias Deliver shock for ventricular arrhythmias

What Functions do the devices perform? Loop recorders Record abnormal rhythms automatically Patients can activate the device to record on demand

Basic Pacemaker Functions Pace the heart at a programmed rate Sense the hearts intrinsic rhythm and inhibit pacing, so the pacemaker does not compete with the intrinsic rhythm Sense an intrinsic signal and trigger a response. Modes AAI VVI DDD AOO VOO DOO

Basic ICD Functions Same as pacemaker for the pacing portion of the device Detect VT and VF Deliver anti-tachycardia pacing (ATP) Deliver a shock

What do Magnets do to devices? Pacemakers Temporarily place the device in a non-sensing mode The device will not respond to a sensed event and will continue to pace at a set rate The device will automatically return to previous programming when the magnet is removed Rate is dependent on each different manufacturer and can sometime vary based on the battery life of the device ICD Suspends the detections and therapies in the defibrillator portion of the device only. Pacemaker functions are left unchanged. Removing the magnet will automatically unsuspend the detection and therapy portion of the device Loop recorders No effect

Is there an advantage to using a magnet during a procedure? 2011 HRS/ASA Expert Consensus Statement on the Perioperative Management of Patients with Implantable Defibrillators, Pacemakers, and Arrhythmia Monitors: Facilities and Patient Management http://www.hrsonline.org/Policy-Payment/Clinical-Guidelines-Documents/Expert- Consensus-Statement-on-the-Perioperative-Management-of-Patients-with-Implantable- Defibrillators-Pacemakers-and-Arrhythmia-Monitors/2011-Expert-Consensus-Statement- on-the-Perioperative-Management-of-Patients-with-Implantable-Defibrillators- Pacemakers-and-Arrhythmia-Monitors

Is there an advantage to using a magnet during a procedure? ICD-ON Registry for Perioperative Management of CIEDs: Most Require No Change JANET GIFFORD, M.S.N., A.C.N.P.,* KAREN LARIMER, PH.D., A.C.N.P., F.A.H.A.,† CELIA THOMAS, M.S.N., C.N.S.,* and PATRICIA MAY, M.S., A.C.N.P.‡ - PACE: Feb 2017 “Our findings support that perioperative CIED management should be individualized based on surgical location. If surgical location is within 6 inches of the CIED, reprogram ICD therapies off and if pacemaker dependent change to asynchronous pacing. For ICD patients with surgical location above the iliac crest yet greater than 6 inches from the ICD, use a magnet. And finally, no change for any pacemaker greater than 6 inches from the surgical site, and no change for any ICD with surgeries that occur below the iliac crest.”

Is there an advantage to using a magnet during a procedure? Often the best approach is to have the patient’s EP decide whether to reprogram or use magnet. As in all things, patient care is enhanced with cooperation between disciplines. Reprogramming for surgery means the device MUST be reprogrammed to its normal function after the surgery is complete. If a magnet is used, the device will automatically return to normal function and no reprogramming is needed Often the decision to reprogram will be based on several issues: Is the patient dependent Does the patient need to maintain a specific heart rate during the procedure How close is the surgery site to the device What equipment will be used during surgery How to contact EP: 561-3211 – ask to speak to the physician’s nurse

What if a Device Malfunctions during the procedure? Remember BLS and ALS – treat the patient, not the device REMOVE THE MAGNET: If an ICD patient has a magnet on and has VF/VT, take the magnet off immediately. The device will shock more quickly than you can get the external defibrillator set up. How to page the EP on call: 222:EPMD (3763) How to page the on call rep to reprogram a device or if you have an emergency during a procedure Medtronic: 1-800-MED-TRON (633-8766) Abbot (St. Jude Medical): 1-800-722-3423 Boston Scientific Corp:1-800-CAR-DIAC (227-3422) Biotronik: 1-822-284-6689

Monitoring Considerations during procedure 1. Keep an eye on the BP and O2 Sat as well as the heart monitor 2. Don’t be too worried if you don’t see a pacer spike - they are sometimes very small on the monitor 3. If you do have to defibrillate, try not to place electrodes directly over the device, and have the device interrogated by a rep as soon as feasible after the crisis has passed. 4. If there is concern about the device, do not hesitate to call EPMD on call, or Rep on call 5. If you have specific, non-urgent questions, you can call the device clinic at 561- 3211. 6. If the device was reprogrammed prior to the procedure, be sure that a rep has been in and reprogrammed to device to pre-procedure settings before discharge.

A couple of special issues Loop Recorders: No action is needed – no pacing or therapy functions on these devices – recording only S-ICD No pacing function with this device No leads in the heart Magnet is almost always the best choice for this device during surgery Boston Scientific has the only S-ICD on the market Leadless Pacemaker Magnet cannot be used to place this device in non-sensing mode and the device rep will need to reprogram it before and after the procedure Currently the Medtronic Micra device is the only one on the market

Leadless system

S-ICD

Implantable Loop Recorder