1. Cardiac Implantable Devices
Nursing Care:
The Basics and Beyond

2. Welcome! Terri Rhodes, RN, BSN Laura Hess, RN, BSN
Clinical Level III, CEP Lab Nurse
Laura Hess, RN, BSN
Clinical Level II, CEP Lab Nurse
Please feel free to ask questions during the presentation!

3. Objectives: Examine device terminology
Examine the components, functions and indications for a pacemaker
Inventory the components, indications and functions of an internal cardiac defibrillator (ICD)
Compare the pacing modes using NBG pacing code system
Assess patient needs preoperatively
Manage patient postoperatively
Analyze rhythm strips for appropriate pacemaker and ICD functioning

4. Outline 1. Welcome and general information 2. Pacemakers 3. ICD’s
4. NBG codes
5. Biventricular Pacing
6. Nursing Considerations
7. Pacemaker Practice Strips

5. Normal Conduction System

6. A Brief History of Implantable Devices
First human implant
Dr. Senning in Stockholm, only lasted 3 hours
1960- First clinically successful human implant
Dr’s Chardack and Gage in the US
William Greatbatch, engineer
1965- First VVI implanted
1972- Partially programmable
1977-Multiprogrammable
1981- Dual chamber multi-programmable

7. Along Came ICD’s… 1980 - First human implant Thoracotomy
Epicardial patch & lead
Large device placed in abdomen
Not programmable; i.e. only one setting
Second generation ICD
Transvenous electrode
Bradycardia & anti-tachycardia pacing
Fifth generation
Dual-chamber rate responsive pacing
Improved recognition of SVT
The Next Generation
Remote interrogation
CHF Management
S-ICD- subcutaneous ICD

8. General “Device” Terms to Understand
Sense
Fire
Capture

9. Sense
Sense: the ability of the device to recognize the presence or absence of an innate “p” wave or “qrs” complex

10. Fire
Fire: the device has sensed a missed “p” wave or “qrs” complex, and has sent energy down the pacing wire to the tissue

11. Capture
Capture: the energy has contracted the myocardial tissue, and resulted in a “p” wave or “qrs” complex on skin leads

12. Device Terms Continued…
Failure to Capture:
A spike is noted on strip, but is not followed by appropriate “p” or “qrs” wave form
Failure to Sense
Spike (energy) is missing during absence of “p” or “qrs”
Spike noted at inappropriate times
R on T
Occurs when device fails to sense, and delivers energy during vulnerable T wave - or – if programmed at VOO/AOO, the pacemaker delivers the energy in spite of intrinsic activity and paces on the t-wave.
Failure to Fire
Device does not send energy (pacer spike) when indicated
***If you notice any of these, check your patient, check pulse and notify physician***

13. What Do You Need To Have a Paced Beat?
Atrial Paced Beat:
“a” pacing spike
P wave immediately following pacer spike
Ventricular Paced Beat:
“v” pacing spike
QRS immediately follows pacing spike

15. Examples of Paced “a”, Paced “v”, and Both

16. Pacemakers

17. What is a pacemaker?
A internal device that regulates electrical impulses through the heart.
Sense
Fire
Capture
Single Chamber, Dual Chamber and Bi-Ventricular

18. Pacemaker Components
Pulse generator- battery which provides the energy. Controls the rate, output, and sensitivity.
The “Can”
Leads- carries the impulse to the heart tissue
Atrial
Right Ventricle
Left Ventricle
Coronary Sinus

20. Indications for pacemakers
Symptomatic 2nd degree, Mobitz Type II heart block
Complete heart block (3rd degree)
Asystole
Symptomatic bradycardia
Sinus node dysfunction
Carotid sinus syndrome and hypersensitivity
An exaggerated response to carotid sinus baroreceptor stimulation. Sometimes even mild stimulation in the neck region causes a marked decrease in heart rate, blood pressure, and causes syncope.

21. Other Indications S/P Alcohol Septal Ablation
Hypertrophic Obstructive Cardiomyopathy (HOCM)
S/P Alcohol Septal Ablation
Congestive heart failure (CHF) Biventricular pacing

22. Magnet Placement for a Pacemaker
Temporarily changes the mode of pacing to asynchronous (VOO, DOO) while magnet is in place.
Paces regardless of rhythm
This is programmable feature of the device; NOT ONE SIZE FITS ALL

23. Break???

24. Intracardiac Cardioverter Defibrillators or ICD’s

25. What is an ICD?
An internal device that can regulate electrical impulses through the heart, but its main function is to detect and terminate tachy arrhythmias.
Defibrillation
Override pacing
Cardioversion
Pacemaker Functions (Single/Dual/BiV)

26. Components of an ICD
Pulse generator- battery which provides the energy. Detects tachy arrhythmias and delivers defibrillation energy when indicated. Controls the rate, output, and sensitivity of the pacemaker function.
The “Can”
Leads- carries the impulse to the heart tissue
Right Ventricle
Endo Coil – High output lead
Atrium
Pacemaker lead
Left Ventricle
Placed via the Coronary Sinus when placed in EP lab, and epicardial when placed in OR

27. Unipolar ICD

28. Indications for ICDs Secondary prevention (already had event)
Sudden Cardiac Death; NSVT, Sustained VT, V-fib arrest
Inducible VT (EP testing)
Primary prevention (trying to treat FIRST event)
Cardiomyopathy (SCD-HeFT)
At risk for sudden cardiac death
Unknown etiology
Long QT
Brugada Syndrome (Na channel abnormality resulting in RBBB with J point elevation and concave ST elevation)
Cardiac Sarcoid

29. And the Latest… S-ICD
The S-ICD System is intended to provide defibrillation therapy for the treatment of life-threatening ventricular tachyarrhythmias in patients who do not have: *symptomatic bradycardia *incessant VT *spontaneous, frequently recurring VT that is reliably terminated with anti-tachycardia pacing

30. Which one do you want? Traditional ICD S-ICD
*Provides effective defibrillation *Provides effective defib for
for ventricular arrhythmias ventricular arrhythmias
*Provides brady pacing *No risk of vascular injury
*Provides ATP pacing *Low risk of systemic injury
*Provides atrial diagnostics *Preserves venous access
*Familiarity of implant technique *Avoids risk of endovascular lead extraction

31. Magnet Placement for an ICD
Suspends tachycardia detection while the magnet is in place
Pacing parameters remain unchanged
This is a programmable feature of the ICD, and may be different

32. Caution!
Place magnet on device ONLY under guidance or supervision from a physician or Electrophysiology Department nurse.
Examples of when placing magnet is appropriate:
ICD “ shocking” at inappropriate times
During OR procedures requiring cautery. Stat pads must be placed on patient.
During a code situation when you want to take ‘control of the shocking’

33. Special Considerations for Pt’s with ICD’s
If ICD discharges?
1. Check your pt: Think BLS/ACLS!
ABC’s, is pt. responsive, what rhythm are they in?
Take appropriate action if pt. is not stable
2. If pt. is stable notify EP department
During a CODE?
DO NOT place STAT pads directly over device
UCH policy: Place external defibrillator pads 4-6 inches away from the device laterally if possible.
Pt. is going for another OR procedure
Notify Anesthesia that pt. has device, tell them the company and they will notify the EP department

34. Break?

35. NBG Codes
Generic code created for NASPE and BPEG. (NASPE is the North American Society of Pacing and Electrophysiology. BPEG is the British Pacing and Electrophysiology Group.)
Pacemaker programming codes that identifies how the pacemaker is programmed to function.

36. NBG Codes: Programming the pacemaker
I- What chamber do you want to pace?
II- What chamber do you want to sense?
III-What do you want to do with the sensed information? Inhibit pacing or trigger pacing?
Tracking the Atrial activity
IV-Do you want to increase the rate with the patient’s activity?
Generic code created for NASPE and BPEG. NASPE is the North American Society of Pacing and Electrophysiology. BPEG is the British Pacing and Electrophysiology Group.

37. NBG Code Review P: Simple programmable V: Ventricle V: VentricleII
III IV
Chamber
Chamber
Response
Programmable
Paced
Sensed
to Sensing
Functions/Rate
Modulation
P: Simple programmable
V: Ventricle
V: Ventricle
T: Triggered
M: Multi- programmable
A: Atrium
A: Atrium
I: Inhibited
D: Dual (A+V)
D: Dual (A+V)
D: Dual (T+I)
C: Communicating
O: None
O: None
O: None
R: Rate modulating
S: Single
(A or V)
S: Single
(A or V)
O: None

38. The NBG pacing code I II III IV Position Category Letters Used
Manufac-
turer’s
Designation
Only I II
III
Chamber(s)
Paced
Sensed
Response
to Sensing
Programmability,
rate modulation
O-None
R-Rate modulation
A-Atrium
V-Ventricle
D-Dual
(A+V)
S- Single
(A or V)
T-Triggered
I-Inhibited
(T+I) IV

39. The NBG pacing code I II III IV Position Category Letters Used
Manufac-
turer’s
Designation
Only I II
III
Chamber(s)
Paced
Sensed
Response
to Sensing
Programmability,
rate modulation
O-None
R-Rate modulation
A-Atrium
V-Ventricle
D-Dual
(A+V)
S- Single
(A or V)
T-Triggered
I-Inhibited
(T+I) IV

40. The NBG pacing code I II III IV Position Category Letters Used
Manufac-
turer’s
Designation
Only I II
III
Chamber(s)
Paced
Sensed
Response
to Sensing
Programmability,
rate modulation
O-None
R-Rate modulation
A-Atrium
V-Ventricle
D-Dual
(A+V)
S- Single
(A or V)
T-Triggered
I-Inhibited
(T+I) IV

41. The NBG pacing code I II III IV Position Category Letters Used
Manufac-
turer’s
Designation
Only I II
III
Chamber(s)
Paced
Sensed
Response
to Sensing
Programmability,
rate modulation
O-None
R-Rate modulation
A-Atrium
V-Ventricle
D-Dual
(A+V)
S- Single
(A or V)
T-Triggered
I-Inhibited
(T+I) IV

42. How Do We Use The NBG Language?
Single Chamber Pacing
How Do We Use The NBG Language?

43. * VOO Ventricular pacing No sensing
Ventricular asynchronous pacing at lower programmed pacing rate
Used for: surgical procedures with cautery
Ventricular lead *

44. * VVI I Ventricular pacing Ventricular sensing
Sensed intrinsic QRS inhibits ventricular pacing
Used if patient is in A-fib, do not want to tract the atrial rate I
Ventricular lead *

45. * AOO Atrial pacing No sensing
Atrial asynchronous pacing at lower programmed pacing rate
Atrial lead *

46. * AAI Atrial pacing Atrial sensing
Intrinsic P wave inhibits atrial pacing
Atrial lead *
Indications: Sinus Node Dysfunction

47. Tracking Mode: Both triggers and inhibits pacing
Dual Chamber Pacing
Tracking Mode:
Both triggers and inhibits pacing

48. Benefits of Dual Chamber Pacing
Provides AV synchrony
Lower incidence of atrial fibrillation
Lower risk of systemic embolism and stroke
Lower incidence of new congestive heart failure
Lower mortality and higher survival rates
Studies have been done that demonstrate the differences in outcome, hemodynamic improvement, and quality of life assessment by using AV synchronous, or "atrial-based," pacing modes instead of VVI/R. Some of the benefits of using an atrial-based pacing mode include:
AV synchrony–Clinical benefits such as increased cardiac output, augmentation of ventricular filling (especially important for the majority of the pacing population with LVD and reduced compliance from effects of aging). Providing AV synchrony minimizes valvular regurgitation, and preserves atrial electrical stability.
In the Framingham Study, the development of chronic AF was associated with a doubling of overall mortality and of mortality from cardiovascular disease (Kannel, 1982) The following emphasize the importance of preventing atrial fibrillation:
Patients with AF unrelated to rheumatic or prosthetic valvular disease have a risk of ischemic stroke about five times higher than those with normal sinus rhythm.
AF is associated with over 75,000 cases of stroke per year.
See bibliography for listing of studies cited.

49. Atrial undersensing only (capturing ok)49

50. DDD * * I Pacing in both the atrium and ventricle
Sensing in both the atrium and ventricle
Atrial lead *
Intrinsic P wave and intrinsic QRS can inhibit pacing
Ventricular Lead I *
Intrinsic P Wave can “trigger” a paced QRS
Maintain AV synchronization

51. DDD pacing
Dual-chamber pacing capable of pacing and sensing in both the atrial and ventricular chambers of the heart
4 distinct patterns can be observed with DDD pacing

52. DDD pacing
Sensing in both the atrium and the ventricle (inhibiting in both the atrium and the ventricle)

53. DDD pacing
Pacing in the atrium with sensing (inhibition of pacing) in the ventricle

54. DDD pacing
Sensing in the atrium (inhibition of atrial pacing) and pacing in the ventricle
Also known as “P wave tracking”

55. DDD pacing
Atrial pacing and ventricular pacing (no inhibition of pacing)

56. DDD mode May resemble other modes of pacing
Will strive to maintain AV synchrony with variable atrial rates and AV conduction

57. Dual Chamber Timing Parameters
Lower rate
Upper rate intervals
Dual-chamber pacing requires attention to these parameters:
Lower rate
AV and V-A intervals
Upper rates
Refractory periods
Blanking periods

58. Lower Rate
The lowest rate the pacemaker will pace the atrium in the absence of intrinsic atrial events
Lower Rate Interval
In order to provide optimal hemodynamic benefit to the patient, dual-chamber pacemakers strive to mimic the normal heart rhythm. In dual-chamber pacemakers, the lower rate is the rate at which the pacemaker will pace the atrium in the absence of intrinsic atrial activity. Similar to single-chamber timing, the lower rate can be converted to a lower rate interval (A-A interval), or the longest period of time allowed between atrial events. AP AP VP VP
DDD 60 / 120
New Slide

59. DDDR 60 / 100 (upper tracking rate)
The maximum rate the ventricle can be paced in response to sensed atrial events {
Lower Rate Interval
Upper Tracking Rate Limit
SAV VA
SAV VA
The sequence of an atrial intrinsic event being sensed, starting an SAV interval, timing out the SAV interval, and pacing in the ventricle can be referred to as "tracking." If the atrial rate begins to increase and continues to increase, is it desirable to let the ventricle "track" to extremely high rates? No. It is desirable to limit the rate at which the ventricle can pace in the presence of high atrial rates. This limit is called the upper tracking rate. AS VP
DDDR 60 / 100 (upper tracking rate)
Sinus rate: 100 bpm
New Slide

60. Rate responsiveness/ adaptive-rate pacing
The 4th Letter in the NBG Code

61. Rate responsiveness/adaptive-rate pacing
Rate response attempts to mimic the sinus node by increasing heart rate in response to increasing metabolic demand

62. Rate responsiveness/adaptive-rate pacing
Sensor(s) detect changes in physiologic needs and increase the pacing rate accordingly

63. Rate responsiveness/adaptive-rate pacing
The sensor detects changes by:
Sensing motion (crystal or accelerometer)
Sensing changes in intrathoracic impedance, e.g., minute ventilation

64. Example of Dual-Chamber Rate-Responsive pacing
DDDR pacing
Example of Dual-Chamber Rate-Responsive pacing

65. Biventricular PPM or ICD
A Brief Overview of What It Means To BiV Pace

66. Three lead system: Right atrial Right ventricular Left ventricular
Biventricular pacing
Three lead system:
Right atrial
Right ventricular
Left ventricular

67. Biventricular pacing

68. Cardiac Resynchronization Therapy (CRT)
Patient Indications
Bi-Ventricular ICD
Moderate to severe HF (NYHA Class III/IV) patients
Symptomatic despite optimal, medical therapy
QRS  130 msec
LVEF  35%

69. Biventricular pacing
Also known as cardiac resynchronization therapy, keeps the right and left ventricles pumping together by sending small electrical impulses to the heart muscle coordinating their contractions.
The heart is able to fill and pump blood more effectively. This along with medical therapy, helps to improve heart failure symptoms.
Improves quality of life in many.

70. Biventricular pacing Achieved by:
Inhibiting intrinsic ventricular rhythm
Ensure pacing in RV and LV
Short A-V delays to promote pacing in the ventricle

71. Break?

72. When Devices Go Bad!!!!

73. Complications of Device Implantation:
Pocket hematoma
Pocket infection
Pneumothorax
Cardiac perforation
Cardiac tamponade
Vascular damage
Lead dislodgement
Lead fracture
Lead infection
Inappropriate shocks

74. Laser Lead Extraction Program
Implemented at UCH in 2008 by Chancey Weaver RN and Dr. Michelle Khoo M.D.
First laser lead extraction in January 2009
~30 leads extracted/year
Reasons for a lead extraction:
Fractured Leads
Infected Lead(s)
Non-functional leads/too many leads
Regaining venous access

75. Unexplained Dents!

76. Device Erosion

77. Lead Fracture

78. Intraprocedure

79. Extracted Lead

80. Extracted Generator and Lead

81. Nursing Considerations
Preoperative ICD Placement
and
Postoperative Care

82. Preoperative Left/right arm IV Reinforce patient and family education
EP department performs education prior to and after procedure, any further questions, please call the EP lab
NPO
Surgical site
Pre-op medications
Antibiotics
Blood work (WBC, Platelets, INR, Basic)
Anesthesia in the procedure
Restrictions after procedure

83. Postoperative Vital signs
Changes may indicate pericardial effusion or pneumothorax
Type of device and settings
ECG interpretation and documentation, as per unit guidelines
Activity
HOB <30 degrees for the first 4 hours
Antibiotics
Incision site
X-ray within 1 hour of arriving back in room and
X-ray in AM as well
**Pt. placed in sling for 24 hours to allow leads to adhere to tissue**

84. Documentation According to hospital policy:
University of Colorado Hospital
Call report to telemetry: Include device manufacturer and model number, mode (VVI, DDD, etc.), and lower and upper programmed rates (should be given in report).
Place in computerized documentation: Device manufacturer, mode, rate, rate cut off, therapies, and date of implant.
If the device fires, document any therapies of the device including the precipitating dysrhythmia and outcome in your charting. Include ECG strips, if available, documenting the dysrhythmia, the delivery of the therapy via the ICD and the resultant rhythm and the patient response.

85. Strip Documentation
According to hospital policy, and individual unit guidelines.
Minimal information includes “running” a strip every 12 hours or with a change in rhythm
Documentation: date, time, patient's name, medical record #, heart rate, PR, QRS, and QT intervals, and rhythm analysis

86. Patient and Family Education
Wound care
S/S of infection
No submersion under water for 3 weeks
No direct water spray (shower spray) for 1 week
Coughing and deep breathing
Activity
All information in Post Op packet
NO lifting arm above shoulder for 6 weeks
Follow-up appointment
Remote interrogations
Electromagnetic interference
Identification card

87. Patients Admitted With a PPM or an ICD

88. Patients admitted with a PPM/ICD
Ask patient for device information, i.e. registration card
EP does not need to be consulted if a patient is admitted for a non-device related problem and the device appears to be working appropriately.
MRI not recommended (except new Medtronic PPM)
Pre-op/Post-op patients may require device programming changes
ICD- tachy therapies off, or may fire during cautery
PPM- reprogram to VOO, or may fail to pace appropriately

89. Pacemaker Practice Strips

90. What You Need to Document
Underlying rhythm?
Is it “a” paced, “v” paced or both
Is the device doing what it is programmed to do?

91. Troubleshooting
Failure to:
Sense
Fire
Capture

92. How to interpret a “paced” strip: One method of many…
Is intrinsic activity present?
Are pacing spikes present: “A”, “V”, or both?
Is 1:1 capture present?
Is intrinsic activity sensed appropriately?
Over sensing- sensing of an inappropriate single
Leads to underpacing
Under sensing- failure to sense intrinsic cardiac signal
Results in overpacing
What is the heart rate?
What is the programmed pacing rate?
Compliments of Northwestern Memorial Hospital, October 2002

93. Is This Normal Device Operation?
Answer: Yes. Device is programmed to VVI; rate 60.

94. Is This Normal Device Operation?
Answer: Yes. This is DDD Pacing. Programmed parameters are: DDD, Lower Rate 60, Upper Rate 120.

95. What Device Operation is This?
Answer: Ventricular Safety Pacing, coincident with a PVC.
Programmed parameters:
DDD
Lower rate 60 ppm
Upper tracking rate 120 ppm
PAV 180 ms
SAV 150 ms
PVARP 310 ms
VSP “on”

96. Is This Normal Device Operation?
Answer: Yes. The device is programmed to the DDI mode–hence, no atrial tracking.
Programmed parameters:
DDI; 60; PAV 150.

97. Is This Normal Device Operation?
Answer: Yes. This ECG is an example of atrial synchronous pacing in the VDD mode in the first five complexes, followed by ventricular pacing as the atrial rate drops below the lower rate in the last two complexes.
Programmed parameters:
VDD; lower rate 60; upper rate 120.

99. What is missing?
Lack of V capture 99

102. Atrial pacemaker

104. DOO pacing mode
104

107. Atrial undersensing only (capturing ok)
107

108. Thank You Cardiac Electrophysiology William H. Sauer, MD
Dena Keilman, RN
Kari Jackson, RN
Noelle Hernandez, RN
Amanda Lange, RN
Heidi Huber, RN
Terri Rhodes, RN
Dan Sullivan, RN
Claire Rutherford, RN
Matt Upton, RN
Laura Hess, RN
Diane Ridgway, RN
Ann Czyz. RN
William H. Sauer, MD
Duy Nguyen, MD
Paul Varosy, MD
Ryan Aleong, MD
Joe Schulller, MD
Wendy Tzou, MD
Christine Tompkins, MD
David Katz, MD
Cathy Kenny, ANP

109. References
Burke M, et al. Safety and Efficacy of a Subcutaneous Implantable-Defibrillator (S-ICD System US IDE Study). Late-Breaking Abstract Session. HRS 2012.