1. Department of Anesthesia and Perioperative Care advancing health worldwide TM Combined ICD/Pacing Devices What options are available? What’s new in the pacing world? William A. Shapiro, M.D. http://anesthesia.ucsf.edu/shapiro

2. Department of Anesthesia and Perioperative Care advancing health worldwide TM What’s Not New - Your Best Friend Charles L. Witherell, RN, ACNS-BC, MSN Charles L. Witherell, RN, ACNS-BC, MSN Clinical Nurse Specialist, Pacemakers Clinical Nurse Specialist, Pacemakers Cardiac Electrophysiology Service Cardiac Electrophysiology Service UCSF Arrhythmia and Device Clinic UCSF Arrhythmia and Device Clinic 350 Parnassus Ave., Room 204 350 Parnassus Ave., Room 204 Pager: 415 443-3786 Pager: 415 443-3786 Voicemail: 415 353-4032 Voicemail: 415 353-4032

3. Department of Anesthesia and Perioperative Care advancing health worldwide TM The algorithms that each company uses to create their ICDs and Pacemakers are among the company’s most closely guarded secrets. What’s Not New

4. Department of Anesthesia and Perioperative Care advancing health worldwide TM The Pacemaker Companies Medtronic: http://www.medtronic.com Medtronic: http://www.medtronic.com St. Jude Medical: http://www.sjm.com St. Jude Medical: http://www.sjm.com Boston Scientific- http://www.bostonscientic.com Boston Scientific now owns Guidant Boston Scientific- http://www.bostonscientic.com Boston Scientific now owns Guidant All 3 have humans answering the phone 24/7/365 All 3 have humans answering the phone 24/7/365 FDA- http://www.fda.gov/cdrh FDA- http://www.fda.gov/cdrh AHA- http://www.americanheart.org AHA- http://www.americanheart.org

5. Department of Anesthesia and Perioperative Care advancing health worldwide TM The Pacemaker Card Physician’s name Physician’s name Generator and lead serial numbers Generator and lead serial numbers Manufacturer tech support number Manufacturer tech support number The pacemaker card does not contain any information about the current programmed mode, the magnet response, the reason it was inserted, or when the pacemaker was last checked

6. Department of Anesthesia and Perioperative Care advancing health worldwide TM Guidant T-180 (ICD/Pacemaker) First released in 2005. This model is still available. ICD- Defibrillation for V-fib, or rapid V-tach Anti-bradycardia pacing- ventricular pacing only. It only has an inhibited (synchronous) mode. Fixed-rate (asynchronous) pacing is not a programmable option. The ventricular rate is programmable, but of course, it will always remain in the VVI mode after programming. It cannot be put into a permanent fixed-rate pacing mode. Not to be confused with the T-1000, which is the “fictional” android assassin featured as the main antagonist in Terminator 2: Judgment Day (released in 1991).

7. Department of Anesthesia and Perioperative Care advancing health worldwide TM Why might a pacemaker not have an asynchronous mode option? Why might a pacemaker not have an asynchronous mode option? What is the danger of an asynchronous mode option? (Hint- Same as question above) What is the danger of an asynchronous mode option? (Hint- Same as question above) Answer: The companies are afraid of a fixed rate pacemaker spike causing an R-on-T induced ventricular tachycardia or ventricular fibrillation. Answer: The companies are afraid of a fixed rate pacemaker spike causing an R-on-T induced ventricular tachycardia or ventricular fibrillation. Guidant T180 (ICD/Pacemaker) (Guidant is now Boston Scientific)

8. Department of Anesthesia and Perioperative Care advancing health worldwide TM Pacemaker Induced “R on T” Arrhythmia

9. Department of Anesthesia and Perioperative Care advancing health worldwide TM All 3 American Pacemaker/ICD companies now provide ICD/Anti- bradycardia pacemakers in which the ICD function can be inhibited, and the anti-bradycardia pacing can be programmed into either the inhibited or asynchronous (fixed-rate) mode. What’s New ?

10. Department of Anesthesia and Perioperative Care advancing health worldwide TM Technology marches forward- generators will have more options. The devices will get smaller and lighter. New combined ICD/Pacemakers now have an “on/off Electrocautery” mode. Once the ICD is off, the pacer can be either fixed rate or inhibited. Pacing can be VOO, AOO, or DOO, at any rate. What’s New ?

11. Department of Anesthesia and Perioperative Care advancing health worldwide TM Minimal Ventricular Pacing (MVP): A proprietary Medtronic feature where the pacemaker learns to reset its own mode from sensing the patient’s cardiac conduction properties. AAI->DDD Minimal Ventricular Pacing (MVP): A proprietary Medtronic feature where the pacemaker learns to reset its own mode from sensing the patient’s cardiac conduction properties. AAI->DDD In-home wireless monitoring of pacemaker activity. The information is sent to a remote “secure” company database. In-home wireless monitoring of pacemaker activity. The information is sent to a remote “secure” company database. What’s New ?

12. Department of Anesthesia and Perioperative Care advancing health worldwide TM What’s Not New - Your Best Friend Charles L. Witherell, RN, ACNS-BC, MSN Charles L. Witherell, RN, ACNS-BC, MSN Clinical Nurse Specialist, Pacemakers Clinical Nurse Specialist, Pacemakers Cardiac Electrophysiology Service Cardiac Electrophysiology Service UCSF Arrhythmia and Device Clinic UCSF Arrhythmia and Device Clinic 350 Parnassus Ave., Room 204 350 Parnassus Ave., Room 204 Pager: 415 443-3786 Pager: 415 443-3786 Voicemail: 415 353-4032 Voicemail: 415 353-4032