Παρουσίαση περιστατικών με icd-alarm sounding και δυσλειτουργία καλωδίων. Χ. ΧΑΤΖΗΕΛΕΥΘΕΡΙΟΥ, Α. ΤΣΑΓΚΡΙΔΗ, Α.ΤΣΑΟΥΣΙΔΗΣ, Β. ΣΑΑΤΣΟΓΛΟΥ, Π. ΚΩΝΣΤΑΝΤΙΝΙΔΗΣ, Ι. ΟΥΖΟΥΝΙΔΗΣ, ΕΙΡ.ΣΑΒΒΙΔΟΥ, Ν. ΡΩΜΑΝΙΔΟΥ, Χ. ΚΕΦΑΛΙΔΗΣ, Ν. ΘΕΟΔΩΡΙΔΗΣ Καρδιολογική κλινική ΓΝΔράμας
Σκοπός α)παρουσίαση περιστατικών που προσήλθαν το τελευταίο έτος με ICD alarm sounding. β)ανασκόπηση βιβλιογραφίας.
1⁰ ΠΕΡΙΣΤΑΤΙΚΟ Άρρεν ασθενής 83 ετών με ΑΙ: ισχαιμική ΚΑ Συνεχόμενες/ώρα δονήσεις και απρόσφορες εκφορτίσεις επί AF και lower heart rate. Τοποθέτηση εξωτερικού μαγνήτη και ICD interrogation. Θραύση απινιδωτικού καλωδίου Απομόνωση ηλεκτροδίου και τοποθέτηση νέου.
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2⁰ ΠΕΡΙΣΤΑΤΙΚΟ Άρρεν ασθενής 63 ετών με ΑΙ: διατατικής μυοκαρδιοπάθειας 1 επεισόδιο alarm sounding. ICD interrogation. Φλεγμονή θήκης-συντηρητική αντιμετώπιση.
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3⁰ ΠΕΡΙΣΤΑΤΙΚΟ Θήλυ ασθενής ετών 30 με ΑΙ: HCM Ακουστικές δονήσεις διάρκειας 20sec 6ωρη παρακολούθηση σε monitorκοιλιακή εκτοπία ICD interrogation Θραύση απινιδωτικών καλωδίων Αφαίρεση και επανατοποθέτηση
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Guidelines for management of patients presenting to emergency department with ICD alarm sounding: Patients who present during office hours are to be referred for ICD-interrogation Patients who present out of hours are to be managed as follows: 1)Be admitted to hospital 2)Magnet to be secured over the ICD to suspend all tachyarrhythmia therapies and therefore prevent development of inappropriate shocks 3)Patients are to be placed in telemetry
4) Ward staff to be informed that ICD therapies are inactive 5)Request ICD interrogation as soon as service is available (Cork university Hospital Cardiology department June 2012)
Defective ICD leads 5-10% of leads will break or fail to operate within 15years Age of patient If the vein is occluded How long the leads have been in place 1-2% risk of creating a hole in the vessel or the heart during the removal of the wire
Definitions Lead Extraction: Removal of a lead that has been implanted for more than one year, or a lead regardless of duration of implant requiring the assistance of specialized equipment that is not included as part of the typical implant Lead Explant: A lead removal using simple traction techniques (no locking stylet, telescoping sheaths or femoralextraction tools) Lead Removal: Removal of a pacing or defibrillator lead using any technique (American Heart Association)
Indications for lead extraction Mandatory Advisable Non-advisable Lead-related endocarditis Pocket infection Local infection not responding to conservative therapy Local infection of a pacemaker or ICD pocket Recurrent systemic infection of unknown origin in an ICD patient Superfluous nonfunctional leads that cannot be easily removed (Netherlands Heart Journal 2008 Oct)
Pacemaker and implantable cardioverter defibrillator leads are removed from the inside of the heart by use of specialized tools, such as the laser sheath shown above. Eric Buch et al. Circulation. 2011;123:e378-e380 Copyright American Heart Association, Inc. All rights reserved.
These 3 leads were removed from a single patient. Eric Buch et al. Circulation. 2011;123:e378-e380 Copyright American Heart Association, Inc. All rights reserved.
Classification of complications Major Death Cardiac avulsion or tear requiring thoracotomy, pericardiocentesis, chest tube, or surgical repair Vascular avulsion or tear Pulmonary embolism Minor Pericardial effusion not requiring pericardiocentesis or surgical intervention Hemothorax not requiring a chest tube Hematoma at the surgical site Arm swelling or thrombosis of implant veins resulting in medical intervention Respiratory arrest or anesthesia related complication Stroke Pacing system related infection of a previously non-infected site Vascular repair near the implant site Migrated lead fragment without sequelae Blood transfusion related to blood loss during surgery Pneumothorax requiring a chest tube
REQUIRED PERSONNEL Primary Operator: A physician performing the lead extraction who is properly trained and experienced in device implantation, lead extraction and the management of complications. Cardiothoracic surgeon well versed in the potential complications of lead extraction and techniques for their treatment, on site and immediately available Anesthesia support Personnel capable of operating fluoroscopic equipment Scrubbed assistant (nurse/technician/physician) Non scrubbed assistant Echocardiographer
Safety and efficacy of lead extraction The Lexicon study Safety and efficacy of laser-assisted lead extraction in a large series of consecutive patients 13 centers were included Between January 2004 and December 2007, 1,449 consecutive patients underwent laser-assisted lead extraction of 2,405 leads (20 to 270 procedures/site).
Median implantation duration was 82.1 months Failure to achieve clinical success was associated with: 1) Βody mass index <25 kg/m 2)low extraction volume centers. Procedural failure was higher 1) in leads implanted for 10 years 2)when performed in low volume centers.
Total mortality is substantially increased with pocket infections or device-related endocarditis, particularly in the setting of diabetes, renal insufficiency, or body mass index <25 kg/m2.
Bibliography resources 1) Bruce L. Wilkoff et al Heart Rhythm, Vol 6, No 7, July 2009 2) The Lexicon study, Journal of the American College of Cardiology Vol. 55, No. 6, 2010 Published by Elsevier Inc. 3) Eric Buch et all Pacemaker and Defibrillator Lead Extraction,2011,AHA 4)www.hopkins medicine.ogr/news/publications/cardiovascular
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