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Cardiac Implantable Devices
Nursing Care:
The Basics and Beyond
Welcome!
Terri Rhodes, 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!
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
Outline
1. Welcome and general information
2. Pacemakers
3. ICD’s
4. NBG codes
5. Biventricular Pacing
6. Nursing Considerations
7. Pacemaker Practice Strips
Normal Conduction System
A Brief History of Implantable Devices
 1958 - 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
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
General “Device” Terms to Understand
Sense
Fire
Capture
Sense
Sense: the ability of the device to
recognize the presence or absence of an
innate “p” wave or “qrs” complex
Fire
Fire: the device has sensed a missed “p”
wave or “qrs” complex, and has sent
energy down the pacing wire to the tissue
Capture
Capture: the energy has contracted the
myocardial tissue, and resulted in a “p”
wave or “qrs” complex on skin leads
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***
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
Examples of Paced “a”,
Paced “v”, and Both
Pacemakers
What is a pacemaker?
 A internal device that regulates electrical
impulses through the heart.
Sense
Fire
Capture
Single Chamber, Dual Chamber and Bi-Ventricular
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
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.
Other Indications
Hypertrophic Obstructive
Cardiomyopathy (HOCM)
S/P Alcohol Septal Ablation
Congestive heart failure (CHF)
Biventricular pacing
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
Break???
Intracardiac Cardioverter Defibrillators
or
ICD’s
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)
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
Unipolar ICD
Indications for ICDs
Secondary prevention (already had event)
 Sudden Cardiac Death; NSVT, Sustained VT, Vfib 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
And the Latest…
S-ICD
The S-ICD System is intended to provide
defibrillation therapy for the treatment of lifethreatening ventricular tachyarrhythmias in
patients who do not have:
*symptomatic bradycardia
*incessant VT
*spontaneous, frequently recurring VT that is
reliably terminated with anti-tachycardia
pacing
Which one do you want?
Traditional ICD
*Provides effective defibrillation
for ventricular arrhythmias
*Provides brady pacing
*Provides ATP pacing
*Provides atrial diagnostics
*Familiarity of implant technique
S-ICD
*Provides effective defib for
ventricular arrhythmias
*No risk of vascular injury
*Low risk of systemic injury
*Preserves venous access
*Avoids risk of endovascular lead
extraction
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
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’
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
Break?
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.
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?
NBG Code Review
I
Chamber
Paced
II
Chamber
Sensed
III
Response
to Sensing
IV
Programmable
Functions/Rate
Modulation
V: Ventricle
V: Ventricle
T: Triggered
P: Simple
programmable
A: Atrium
A: Atrium
I: Inhibited
M: Multiprogrammable
D: Dual (A+V)
D: Dual (A+V) D: Dual (T+I)
C: Communicating
O: None
O: None
R: Rate modulating
S: Single
S: Single
(A or V)
(A or V)
O: None
O: None
The NBG pacing code
Position
I
II
III
Category
Chamber(s)
Paced
Chamber(s)
Sensed
Response
to Sensing
Letters
Used
Manufacturer’s
Designation
Only
IV
Programmability,
rate modulation
O-None
O-None
O-None
O-None
A-Atrium
A-Atrium
T-Triggered
R-Rate modulation
V-Ventricle
V-Ventricle
I-Inhibited
D-Dual
(A+V)
D-Dual
(A+V)
D-Dual
(T+I)
S- Single
(A or V)
S- Single
(A or V)
The NBG pacing code
Position
I
II
III
Category
Chamber(s)
Paced
Chamber(s)
Sensed
Response
to Sensing
Letters
Used
Manufacturer’s
Designation
Only
IV
Programmability,
rate modulation
O-None
O-None
O-None
O-None
A-Atrium
A-Atrium
T-Triggered
R-Rate modulation
V-Ventricle
V-Ventricle
I-Inhibited
D-Dual
(A+V)
D-Dual
(A+V)
D-Dual
(T+I)
S- Single
(A or V)
S- Single
(A or V)
The NBG pacing code
Position
I
II
III
Category
Chamber(s)
Paced
Chamber(s)
Sensed
Response
to Sensing
Letters
Used
Manufacturer’s
Designation
Only
IV
Programmability,
rate modulation
O-None
O-None
O-None
O-None
A-Atrium
A-Atrium
T-Triggered
R-Rate modulation
V-Ventricle
V-Ventricle
I-Inhibited
D-Dual
(A+V)
D-Dual
(A+V)
D-Dual
(T+I)
S- Single
(A or V)
S- Single
(A or V)
The NBG pacing code
Position
I
II
III
Category
Chamber(s)
Paced
Chamber(s)
Sensed
Response
to Sensing
Letters
Used
Manufacturer’s
Designation
Only
IV
Programmability,
rate modulation
O-None
O-None
O-None
O-None
A-Atrium
A-Atrium
T-Triggered
R-Rate modulation
V-Ventricle
V-Ventricle
I-Inhibited
D-Dual
(A+V)
D-Dual
(A+V)
D-Dual
(T+I)
S- Single
(A or V)
S- Single
(A or V)
Single Chamber Pacing
How Do We Use The NBG Language?
VOO
• Ventricular pacing
Ventricular
lead
*
• No sensing
• Ventricular asynchronous
pacing at lower programmed
pacing rate
• Used for: surgical
procedures with cautery
VVI
• Ventricular pacing
• Ventricular sensing
Ventricular
lead
I
*
• Sensed intrinsic QRS
inhibits ventricular pacing
• Used if patient is in A-fib, do
not want to tract the atrial
rate
AOO
• Atrial pacing
• No sensing
Atrial lead
*
• Atrial asynchronous pacing
at lower programmed
pacing rate
AAI
• Atrial pacing
• Atrial sensing
Atrial lead
*
• Intrinsic P wave inhibits
atrial pacing
Indications: Sinus Node Dysfunction
Dual Chamber
Pacing
Tracking Mode:
Both triggers and inhibits pacing
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
DDD
Atrial
lead
Ventricular
Lead
• Pacing in both the atrium
and ventricle
• Sensing in both the atrium
and ventricle
• Intrinsic P wave and intrinsic
QRS can inhibit pacing
*
I
*
• Intrinsic P Wave can
“trigger” a paced QRS
• Maintain AV synchronization
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
DDD pacing
Sensing in both the atrium and the ventricle
(inhibiting in both the atrium and the
ventricle)
DDD pacing
Pacing in the atrium with sensing (inhibition
of pacing) in the ventricle
DDD pacing
Sensing in the atrium (inhibition of atrial
pacing) and pacing in the ventricle
Also known as “P wave tracking”
DDD pacing
Atrial pacing and ventricular pacing (no
inhibition of pacing)
DDD mode
May resemble other modes of pacing
Will strive to maintain AV synchrony
with variable atrial rates and AV
conduction
Dual Chamber Timing Parameters
Lower rate
Upper rate intervals
Lower Rate
The lowest rate the pacemaker will pace
the atrium in the absence of intrinsic atrial
events
Lower Rate Interval
AP
DDD 60 / 120
New Slide
VP
AP
VP
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
AS
VA
VP
DDDR 60 / 100 (upper tracking rate)
Sinus rate: 100 bpm
New Slide
SAV
AS
VP
VA
Rate responsiveness/
adaptive-rate pacing
The 4th Letter in the NBG Code
Rate responsiveness/adaptive-rate pacing
Rate response attempts to mimic the
sinus node by increasing heart rate
in response to increasing metabolic
demand
Rate responsiveness/adaptive-rate pacing
Sensor(s) detect changes in
physiologic needs and increase the
pacing rate accordingly
Rate responsiveness/adaptive-rate pacing
The sensor detects changes by:
Sensing motion (crystal or
accelerometer)
Sensing changes in intrathoracic
impedance, e.g., minute ventilation
DDDR pacing
Example of Dual-Chamber RateResponsive pacing
Biventricular PPM or
ICD
A Brief Overview of What It Means To BiV Pace
Biventricular pacing
Three lead system:
Right atrial
Right ventricular
Left ventricular
Biventricular pacing
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%
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.
Biventricular pacing
Achieved by:
 Inhibiting intrinsic ventricular rhythm
 Ensure pacing in RV and LV
 Short A-V delays to promote pacing in the
ventricle
Break?
When Devices Go
Bad!!!!
Complications of Device Implantation:
Pocket hematoma
Pocket infection
Pneumothorax
Cardiac perforation
Cardiac tamponade
Vascular damage
 Lead dislodgement
 Lead fracture
 Lead infection
 Inappropriate shocks
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
Unexplained Dents!
Device Erosion
Lead Fracture
Intraprocedure
Extracted Lead
Extracted Generator and Lead
Nursing Considerations
Preoperative ICD Placement
and
Postoperative Care
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
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**
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.
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
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
Patients Admitted With a
PPM or an ICD
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
Pacemaker Practice
Strips
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?
Troubleshooting
Failure to:
Sense
Fire
Capture
How to interpret a “paced” strip:
One method of many…
1.
2.
3.
4.
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
5. What is the heart rate?
6. What is the programmed pacing rate?
Compliments of Northwestern Memorial Hospital, October 2002
Is This Normal Device Operation?
Is This Normal Device Operation?
What Device Operation is This?
Is This Normal Device Operation?
Is This Normal Device Operation?
What is missing?
Thank You
 Cardiac Electrophysiology












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
References

 Burke M, et al. Safety and Efficacy of a Subcutaneous ImplantableDefibrillator (S-ICD System US IDE Study). Late-Breaking Abstract
Session. HRS 2012.