troubleshootingin pacemaker & icd therapy–practical tips ...€¦ · therapy–practical tips...

12/7/19

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Troubleshooting in Pacemaker & ICD Therapy – Practical Tips & Tricks

M. Firouzi, MD, PhDMaasstad Hospital Rotterdam

No disclosures

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• Failure to Pace (Capture/ Output)

• Sensing Issues

• Timing Cycles

• Case Reports

Outline

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PM & ICD Troubleshooting

・Device data

・Surface ECG

・Chest X-ray

・Clinical symptoms

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- single-chamber pacemaker implanted for AF with

slow ventricular response

- Shortness of breath since a couple of weeks

2312 ohms

81 y/o patient with slow AF

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What do we see here?

1. Ventricular undersensing2. Ventricular oversensing3. Ventricular non-capture4. 1 and 3 are both true

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→ Reprogram unipolar & replace the lead!

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- Dual-chamber pacemaker implanted

- Syncope on ward after implantation

72 y/o patient with 3rd degree AVB

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1 First spike in atrial channel stimulates RV

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1

2

2 Ventricular pacing is inhibited by the detected P waves on the ventricular channel

HEADE

R

SWIT

CH

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70 y/o patient with tachycardia- Dual-chamber pacemaker for SND

- 1 month later, PM interrogation showed episodes of

tachycardia

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This episode of tachycardia is:1. Sinus tachycardia2. Atrial tachycardia3. PM-mediated tachycardia4. Ventricular tachycardia

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↓PVC

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↓PVC

PMT

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PMT

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- At follow-up: fatigue, dyspnea on exertion, nausea

and paroxysmal nocturnal dyspnea

81 y/o patient with single-chamber PM

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Pacemaker syndrome

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Pacemaker syndrome

→ Upgrade to DDD

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ICD Troubleshooting

・Evaluating patients with shocks

・Evaluating absent or ineffective treatment

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・Primary Prevention – No VT/VF (yet) but at high risk

・Secundary Prevention – Survived VT/VF

ICD indications

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・Tertiary Prevention

・Primary Prevention – No VT/VF (yet) but at high risk

・Secundary Prevention – Survived VT/VF

ICD indications

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・Primary Prevention

・Secundary Prevention

・Tertiary Prevention

ICD indications

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Cascade of Events Leading to ICD Shock

ShockTachycardia

Heart rate

threshold

Ignore

slow rhythms

(VT, SVT)

Duration/

no. intervals

Ignore

non-sustained

・Morphologyonset, stability, wavelet・Single/dual chamber

VT

Detection

EnhancementsDiscrimination

Ignore

SVT

ATP

・Terminate VT

・Allow time → self-term

・Terminate some SVT

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Stored & clinical data

Tachyarrhythmia No tachyarrhythmia(oversensing)

Intracardiacsignals

Extracardiacsignals

SVT(inappropriate

detection)

VT/VF(appropriate

detection)

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Stop the Device /Repair the DeviceStop the Arrhythmia

Management of the Patient Receiving Shocks

Stored & clinical data

Tachyarrhythmia No tachyarrhythmia(oversensing)

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1. Myopotential oversensing2. Electromagnetic interference (EMI)3. T Wave oversensing4. Lead fracture5. Loose set screw

Atrial

RV Sensing

Shock

Patient feels dizzy, then receives a shock (not shown)Tracing most consistent with:

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Atrial

RV Sensing

Shock


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Atrial

RV Sensing

Shock


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Dynamic Sensing in VF

ICD dynamic sensing threshold

Filtered & Rectified EGM

Unfiltered EGM

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Swerdlow et al. Circulation 2014

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Oversensing Patterns of Extra-Cardiac Signals

Far field V-EGM

Near field V-EGM

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Oversensing Patterns of Extra-Cardiac Signals

Far field V-EGM

Near field V-EGM

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Called to see patient 2 hours post-implantDDX?

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ICD interrogation: most likely cause of asystole and shock?

1. Crosstalk2. Electromagnetic interference3. Loose set screw4. Air in header5. Lead fracture

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Air in Header

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Loose set screw

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Air in Header

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Lead Fracture/Failure Noise - Key Points

・Non-physiological saturated “sharp” signals

・Intervals <140 msec

・Can lead to syncope (pacing may cease due to

oversensing or lead failure)

・Can lead to inappropriate shock or failed shock

・Lead fracture: high impedance

・Insulation defect: low impedance

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- Single-chamber ICD for ARVC

- No complaints at all

- Multiple shocks at the Gym during exercise

28 y/o woman with shocks

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What is going on?

1. VT

2. SVT3. R-wave double counting

4. T-wave oversensing

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1 Large (exercise induced) T-waves on near field

2 VF detected (FD)

3 Full energy shock (34.9 J)

4 R-amplitude undersensing due to sensing adjustment

1

2 34 4

Near field

Far field

Marker

V-V (ms) ↑

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Oversensing of Physiologic Intracardiac Signals

P wave OS T wave OSR wave double counting (BiV)

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This patient has pacing system malfunctionFrom this image it is clear that it is due to:

1. Lead conductor fracture

2. Lead insulation defect

3. Lead dislodgement

4. Twiddler’s syndrome5. PG failure

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1. Lead conductor fracture

2. Lead insulation defect

3. Lead dislodgement

4. Twiddler’s syndrome5. PG failure

This patient has pacing system malfunctionFrom this image it is clear that it is due to:

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Twiddler’s Syndrome

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This tracing represents: 1. Therapy for SVT (inappropriate)2. Therapy for VT (appropriate)

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60 y/o man with shock

- ICD implanted 7 years ago for HCM

- No previous shocks

- Worked on shipyard all day; mild shoulder discomfort

- Shock while opening jar

- Presents to ER; CXR (-); troponin (-); other labs OK

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A

V


provocative maneuver

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A

V

1. Amiodarone2. Decrease sensitivity3. Lead revision4. Air in the header5. Avoid use of power

tools

You recommend:


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A

V

1. Amiodarone2. Decrease sensitivity3. Lead revision4. Air in the header5. Avoid use of power

tools

You recommend:


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- 5 yrs ago CRT-D implanted for dilated CMP

- 2 yrs later AV node ablation for AF with rapid

ventricular response

- Last FU: because of low R amplitude, RV sensing

configuration changed: RV tip to ring → RV tip to V coil

- 2 weeks later presentation with (pre)syncope

71 y/o patient with lightheadedness

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1 2

T wave oversensing with automatic senitivity adjustment1

2 Due to higher sensitivity, now also AF is detected on the ventricular lead (number of A’s equal to FS markers)

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→ switch back to RV tip to ring

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During BIV pacing no atrial oversensing anymore3

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- Non-ischemic CMP

- 2 months post implantation still no improvement

- LV threshold testing at office:

64 y/o patient with CRT-D implantation

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What is the LV threshold?

1.0.752.1.003.1.254. Something else

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1 LV pacing started with 1.50 V0,4 msec. There is a delay between LVP and an atrialevent (Ab). Further, the RV EGM morphology remains unchanged

2 LVP results in atrial capture on far field EGM

1

2

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68 y/o patient with dilated CMP- Paroxysmal AF treated with amiodarone

- CRT-D implantation (EF 30%, LBBB, NYHA III, OMT)

- At 3 month FU: normal device performance

→ 80% BIV pacing

→ 20% AF burden associated with mode switch: DDI

- Palpitation and fatigue

- Echo: unchanged LVEF, LA volume index 68 ml/m2

- ECG: AF 120-125/min

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What would you recommend to manage her AF and heart failure?1. Pulmonary vein isolation2. Stop amiodarone, perform AV node ablation3. Stop amiodarone, flecainide4. Add diltiazem

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What would you recommend to manage her AF and heart failure?1. Pulmonary vein isolation2. Stop amiodarone, perform AV node ablation3. Stop amiodarone, flecainide4. Add diltiazem

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