Programming and Follow-up Surveillance of Implantable Cardioverter-Defibrillators

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS
  • Assess for appropriate ICD function.
    • Within 72 hours of ICD implantation (in person)
    • Two to 12 weeks after implantation (in person)
    • Every 3 to 12 months (in person or remote)
    • Annually until battery depletion (in person)
    • Every 1 to 3 months at signs of battery depletion
  • Determine battery longevity and lead integrity.
  • Change programmed bradycardia or tachycardia settings.
  • Assess frequency of arrhythmias and ICD therapy, and determine whether symptoms correlate with arrhythmias.
  • Reprogram settings for perioperative management to avoid electromagnetic interference from electrocautery or other electromagnetic interference.
  • Check ICD function after MRI or other events in which the device may have been exposed to electromagnetic interference.
  • Assess cause when an ICD is beeping or vibrating, which suggests battery depletion, lead dysfunction, or other abnormality.
EQUIPMENT
  • Company programmer
  • ECG electrodes
  • Disinfectant wipes for programming wand
ANATOMY
  • Device “anatomy.”
    • There are three basic configurations of an ICD. Single-chamber ICDs have a single lead placed into the right ventricle. Dual-chamber ICDs have two leads placed: one in the right atrium and one in the right ventricle. Biventricular pacemakers have a third lead placed to pace the left ventricle, usually through the coronary sinus. Leads are more frequently placed transvenously through the subclavian, axillary, or cephalic vein but may also be placed epicardially. All ICDs have both pacing capability and the ability to deliver electrical therapy (shock) in programmed configurations and energy. The generator contains a power source, usually a lithium battery, capacitor, sensing circuit, microprocessor, output circuitry, rate-adaptive sensors, and other circuitry and sensors. The device is also capable of storing information for retrieval later regarding arrhythmias, pacing modes, and therapies such as shocks. The outer casing of the generator is usually titanium, to minimize inflammatory reaction.
    • Every manufacturer uses a different programmer for its devices, and programmers are not interchangeable.
  • Diagnostic testing includes examining several standard tests of defibrillator and pacemaker functions.
    • Sensing: the ability of the device to detect cardiac activity.
    • Impedance: a test of lead integrity. Sudden or large increases in lead impedance can indicate a fracture in a lead or loose set screw, and decreases in impedance may indicate a breach of lead insulation.
    • Thresholds: The pacing threshold is the minimum amount of energy in volts and pulse width required to reliably depolarize the chamber being paced by the lead in question. Proper threshold programming establishes an appropriate safety margin so that reliable electrical therapy and pacing occur, while minimizing unnecessary energy consumption to prolong battery life.
    • Magnet response: Device response to magnet placement varies with the manufacturer, but, in general, application of a magnet over an ICD device suspends therapies while leaving pacing functions unchanged.
    • Examination of any events that were recorded and stored since the last device interrogation, such as episodes of tachycardia, bradycardia, or other arrhythmia, and any delivered therapies. Correlation of recorded events with symptoms may aid diagnosis of cardiac conditions.
    • Percentage of time the patient is paced: The pacemaker will read out percentage of time in AS-VS, AS-VP, AP-VS, and AP-VP modes.

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Dizziness, syncope, fatigue, or palpitations should prompt a repeated ICD interrogation.
  • No other specific postprocedural care is usually indicated.
COMPLICATIONS
  • No studies have looked at overall complication rates for cardiac device interrogations/programming sessions. Some common types of device malfunction or malprogramming include the following:
    • Subthreshold pacing
    • Oversensing or undersensing
    • Inappropriate pacing mode or rate
    • Inappropriate shock therapy
RESULT ANALYSIS
  • A generator at ERI or RRT should be replaced within 3 months. A generator at EOL should be replaced immediately.
  • Pacing outputs should be programmed at least 2× threshold voltage or 3× threshold pulse width.
  • High lead impedance suggests lead fracture or loose set screw. Low impedance suggests insulation breach.
  • Ideally, P waves are >1.5 mV, and R waves are >7 mV. Sensitivity should be programmed for an adequate sensing safety margin.
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