Perioperative Sensor and Algorithm Programming in Patients with Implanted ICDs and Pacemakers for Cardiac Resynchronization Therapy

Background: ICDs and pacemakers for cardiac resynchronization therapy (CRT) are complex devices with different sensors and automatic algorithms implanted in patients with advanced cardiac diseases. Data on the perioperative management and outcome of CRT carriers undergoing surgery unrelated to the device are scarce. Methods: Data from 198 CRT device carriers (100 with active rate responsive sensor) were evaluated regarding perioperative adverse (device-related) events (A(D)E) and lead parameter changes. Results: Thirty-nine adverse observations were documented in 180 patients during preoperative interrogation, which were most often related to the left-ventricular lead and requiring intervention/reprogramming in 22 cases (12%). Anesthesia-related events occurred in 69 patients. There was no ADE for non-cardiac surgery and in pacemaker-dependent patients not programmed to an asynchronous pacing mode. Post-operative device interrogation showed significant lead parameter changes in 64/179 patients (36%) requiring reprogramming in 29 cases (16%). Conclusion: The left-ventricular pacing lead represents the most vulnerable system component. Comprehensive pre and post-interventional device interrogation is mandatory to ensure proper system function. The type of ICD function suspension has no impact on each patient’s outcome. Precautionary activity sensor deactivation is not required for non-cardiac interventions. Routine prophylactic device reprogramming to asynchronous pacing appears inessential. Most of the CRT pacemakers do not require surgery-related reprogramming.

A new leadless pacemaker with atrioventricular synchronous pacing replacing a still working VVI leadless pacemaker: a case report

Background A new intracardiac leadless pacemaker (ILP) has been developed to ensure atrioventricular synchrony during ventricular pacing. Recent studies have shown feasibility and safety of accelerometer-based atrial sensing and an improvement in atrioventricular synchrony among patients with atrioventricular block implanted with the Micra AV ILP (Medtronic Inc, Minneapolis, Minnesota, US). However, no data exists about the benefits of a VDD ILP in patients wearing a still working VVI Nanostim ILP (St Jude Medical, St Paul, Minnesota, US). We describe the feasibility of the procedure and the absence of device-related adverse events in the short-term follow-up. Case summary We present the case of a 72-year-old man implanted with a VVI ILP (Nanostim, St Jude Medical, St Paul, MN) on May 2014, who has developed symptomatic high percentage of VVI asynchronous pacing and was treated with an upgrade to synchronous AV PM ILP—Micra AV (Medtronic Inc, Minneapolis, Minnesota, US), which has improved symptoms and functional class. Discussion ILPs represent the best current option for patients requiring pacemaker implantation who are at high risk of infection and bleeding. Our case shows that the new AV synchronous ILP is a good alternative to VVI ILP in patients with sinus rhythm and a strong need for ventricular pacing.

Advanced Cardiovascular Life Support Post–Cardiac Surgery

This chapter explores advanced cardiovascular life support (ACLS) after cardiac surgery. In 2009, the European Association of Cardiothoracic Surgeons provided recommendations for the management of post–cardiac surgery arrest, which have since been augmented by publication of consensus guidelines from the European Resuscitation Council in 2015 and the Society of Thoracic Surgeons in 2017. These guidelines are preferred over traditional ACLS guidelines for cardiac arrest resuscitation of post–cardiac surgery patients. Ventricular fibrillation is the cause of 25%–50% of cardiac arrests in post–cardiac surgery patients. Guidelines recommend up to 3 attempted shocks prior to external cardiac massage (ECM) if they can be delivered within 1 minute of arrest. Early defibrillation is often successful in this population and minimizes potential intrathoracic trauma from ECM on a fresh sternotomy. In patients with severe bradycardia or asystole, the epicardial pacer should be set to emergency mode, which provides dual-chamber, asynchronous pacing at 80–100 bpm with maximum atrial and ventricular amperage. Resternotomy within 5 minutes is recommended when resuscitation after cardiac arrest has been unsuccessful or when cardiac arrest from tamponade is highly likely.