ICD Basics and BeyondICD Basics and Beyond2009.cardiorhythm.com/pdf/19/86.pdf · ICD Basics and BeyondICD Basics and Beyond ... Courtesy of Medtronic Inc . How did we get here?

ICD Basics and BeyondICD Basics and Beyond

ICD Diagnostics: Making the most of it

Dulce Obias-Manno RN, BSN, MHSA, FHRS, CCDS, CEPSCardiac Arrhythmia Center, Device Clinic

Washington Hospital Center, Washington DC

Objectives

The participant will recognize the value f ICD di ti d tof ICD diagnostic data

The participant will learn how to use diagnostic data efficiently at follow-upg y p

ICDs through the years

GEM® DR

1998

Jewel®

1996

PCD™ 7216

1989

GEM® III AT

2001

Maximo®

2003

EnTrust®

2005

GEM® II DR

1999

Micro Jewel® II

1996

PCD™ 7217

1993

Marquis®

2002

Intrinsic®

2004

Virtuoso™

2006

Courtesy of Medtronic Inc

How did we get here?

TransvenousTransvenous leads, active can, pectoral implant,microprocessor

Tiered therapy Biphasic waveform

Shockbox

1985 ---- 1988-89 ---- 1993 -95 ----- 1997 - 99 ---- 2000-02 --- 2004-08

stored intervals, markers

#shocks charge time

Lead data, increased memory, diagnosticsmarkers,

EGMstime diagnostics

Average ICD Implant Timeg p3.74

3.2

2.53

hr)

1.41 1

2

urat

ion

(h

1.11

D

0Epicardial Mono

TransvenousBiphasic

TransvenousBiphasicPectoral

ActiveCan™

Courtesy of Medtronic Inc

How did we get here?AVID CASH SIDS

COMPANION MIRACLE ICD

MADIT MUSTT MADIT IISCD-HeFT

AVID, CASH,SIDS MIRACLE ICD

TransvenousDual chamber

MADIT, MUSTT MADIT II

Transvenous leads, active can, pectoral implant,microprocessor

chamber pacing, Rate-responsive pacing, AT therapies

Minimize RV pacing, CRT-D, capture management


Shockbox

1985 ---- 1988-89 ---- 1993 -95 ----- 1997 - 99 ---- 2000-02 --- 2004-08


Rate histograms, AT/AF events, lead trends, SVT di i i t

#shocks charge time

Lead data, increased memory, diagnostics

Functional status , physiologic measures, t d d ilmarkers,

EGMsdiscriminators, patient alert

time diagnostics trends, daily testing

Annual ICD Implants (approximate)(approximate)

80,000

60,000

(55,400)

40,000(21,000)

(37,100)

20,000

(1 600)(4,200)

(7,800)

(17,200)

(21,000)

01985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

(350)(1,600)

United StatesCourtesy of Medtronic Inc

How did we get here?AVID CASH SIDS

COMPANION MIRACLE ICD

MADIT MUSTT MADIT IISCD-HeFT

AVID, CASH,SIDS MIRACLE ICD

TransvenousDual chamber

Electronic repositioning,

MADIT, MUSTT MADIT II

Transvenous leads, active can, pectoral implant,microprocessor

chamber pacing, Rate-responsive pacing, AT therapies

Minimize RV pacing , CRT-D, capture management

p g,Remote monitoring, wireless telemetry, auto-optimization


Shockbox

1985 ---- 1988-89 ---- 1993 -95 ----- 1997 - 99 ---- 2000-02 --- 2004-08


Rate histograms, AT/AF events, lead trends, SVT di i i t

#shocks charge time

Lead data, increased memory, diagnostics

Functional status , physiologic measures, t d d il

Patient alerts, Auto clinic notification, multiple EGM views,markers,

EGMsdiscriminators, patient alert

time diagnostics trends, daily testing

views, expanded diagnostics

Current Status Current generation ICDs are equipped with

more diagnostic data reflecting ono e d ag ost c data e ect g o

Clinical statusEGM P ti d t d

Device functionality

Hardware integrity

• EGMs: Presenting and stored• Ventricular event logs• Atrial arrhythmia burden• Percent paced, average heart

rate, rate histograms

• Arrhythmia discrimination sequence used

• Pacing appropriate or inappropriate for patient

• Utility of monitored,

• Battery real time measurements/longevity

• Lead real time measurements

• Lead trends, g• Functional status: activity

level, autonomic measures, HR variability, respiratory rate trends, BP and weight monitoring

y ,untreated events

• Evaluation of programmed parameters

• Remote device integrity check

• Lead trends• Intrinsic amplitude trends• Capture threshold trends• Event EGMs, NSVT frequency• Short R-R interval frequency g check

• AV delay optimization occurrence

Increased diagnostic data: B l i th d d thBalancing the good and the badbad

TimeSupplementary data source

Increased battery drain

Time consuming

Overwhelming

Increased diagnostic data: Balancing the good and theBalancing the good and the bad

TimeSupplementary data source

Increased battery drain

Improved battery technology Time consuming

Overwhelming

Improved battery technology

Effici

O ti i

ienc

Optimize

Customizey

Tips for optimizing diagnostic data

•Start with the fundamentals

Summary of events andSummary of events and parameters, presenting EGM, measured values, capture and

i d bsensing data, battery status

•Enhance clinical diagnostics with patient reported symptoms

h th i di i i tiarrhythmia discrimination, arrhythmia burden, lead and

event trends



% pacing, p g,auto

measurements,

historical data etc

h th i di i i ti

data etc

arrhythmia discrimination, arrhythmia burden, lead and

event trends



Case Study #1: Understanding th f d t lthe fundamentals29 year old female with Hx of post-partum CHF, HCM, family history of SD. A dual chamber ICD was implanted for primary prevention on 25 June 2007.p p y pOn Dec 3,2008 the patient reported feeling tired and sent an unscheduled

interrogation. Remote monitoring electrograms are shown . HR: 92 bpm ? accelerated Junctional rhythm ?AVNRT

Case Study #1yDevice Status (Implanted: 25-Jun-2007) Measured on:Battery Voltage (RRT=2.62 V) 3.14 V 03-Dec-2008y g ( )Last Full Charge 9.5 sec 25-Aug-2008

Atrial(4076) RV(6949)SVCS C

Pacing Impedance - - - 392 ohms 03-Dec-2008Defibrillation Impedance RV=49 ohms 03-Dec-2008

SVC=65 ohms 03-Dec-2008Programmed Amplitude/Pulse Width 2 V / 0.4 ms 5 V / 0.8 msProgrammed Amplitude/Pulse Width 2 V / 0.4 ms 5 V / 0.8 msMeasured P/ R Wave 3.1 mV 3.3 mV 03-Dec-2008Programmed Sensitivity 0.9 mV 0.3 mV

Parameter SummaryParameter SummaryMode DDD Lower Rate 40 bpm Paced AV 120 msMode Switch 171 bpm Upper Track 150 bpm Sensed AV 100 msUpper Sensor 130 bpm

Detection Rates TherapiesAT/AF Monitor >171 bpm All Rx OffVF On >207 bpm 35J x 6

Case study#1: FindingsTherapy Summary VT/VF AT/AFPace-Terminated Episodes 0 0Shock-Terminated Episodes 0 0Total Shocks 0 0

Pacing (% of Time Since 21-Nov-2008)AS-VS 100.0%AS-VP < 0.1%AP-VS 0.0%AP VP 0 0%

Total Shocks 0 0Aborted Charges 0 0 AP-VP 0.0%

MVP Off

R Wave AmplitudeAt Implant 16 3 mV Highest 18 3 mV

The patient was seen in clinic on 12/4/08 RV capture was absent The

At Implant 16.3 mV Highest 18.3 mVLast 4.0 mV Lowest 1.7 mV

The patient was seen in clinic on 12/4/08. RV capture was absent. The patient reports she was fishing and pulling heavy nets weeks before the ICD monitoring.

Fluoroscopy revealed RV lead dislodgement to low right atrium. She underwent lead extraction and implantation of a new RV lead.

Tips for optimizing diagnostic dataVerify accuracy of data source

Brady and CRT Counters Since Last Remote Follow-up: 20 Nov 2008

Percent PacedPercent PacedAtrial 0 %Right Ventricular 100 %Left Ventricular 100 %

ATR Mode SwitchNumber of Mode Switches 179Minimum Duration 00:00 mm:ss*Maximum Duration 00:35 mm:ss*a u u a o 00 35 ss*Value based on the most recent 184 ATR episodes collected by LATITUDE.

Tips for optimizing diagnostic datap p g gView data from horizontal

and vertical time linesand vertical time lines

Tips for optimizing diagnostic dataTips for optimizing diagnostic data

Do not obsess over irrelevant details during routine follow-up

“One cannot manage too many affairs:One cannot manage too many affairs: like pumpkins in the water, one pops up while you try to hold down the other “while you try to hold down the other

Chi P bChinese Proverb

Make the most of it !Organize and archive patient data in electronic data storageelectronic data storage

Accessible, confidential

Adjust parameters and automatic alerts parameters tailored to patient’s needs

When troubleshooting, use all data available do manual lead tests obtainavailable, do manual lead tests, obtain patient history then connect the dots

One final pointOne final point

When you don’t understand, seek help f th t (t h i l tfrom the experts (technical support, Electrophysiologist, peers )

“Experience is what you get when you p y g ydidn’t get what you wanted “

Randy Pausch in The Last LectureRandy Pausch in The Last Lecture

Documents

ICD Basics and BeyondICD Basics and Beyond2009.cardiorhythm.com/pdf/19/86.pdf · ICD Basics and BeyondICD Basics and Beyond ... Courtesy of Medtronic Inc . How did we get here?