Troubleshooting Cardiac Rhythm Devices
Contents
1. dee N Den D seg es ania n A oe M Lu sa EE Cay ses TE EP o8 UE 23 BIOTRONIK Loss of Capture Not enough current getting to the lead tip lead is bust lead isn t plugged in correctly Current gets to the tip but the tip but does not capture Drug therapy nfarcts Current gets to the tip but the tip isn t where it should be lead has moved lead is perforated 25 BIOTRONIK excellence for life Loss of Capture Not enough current getting to the lead tip lead is bust impedance changes lead isn t plugged in correctly impedance changes Current gets to the tip but the tip but does not capture Drug therapy drug prescription Infarcts Current gets to the tip but the tip isn t where it should be lead has moved CXR diagnostic tests lead is perforated CXR Echo diagnostic tests CT 25 BIOTRONIK excellence for life Busted leads its all in the resistance Flow of electricity current If you want current arriving at the end of the lead hosepipe you better not stand on the hose A fractured lead a stood on hose pipe Altering impedance alters current water flow High Impedance fractured lead e 0e0e 0 00000000000000000000 Low impedance2. Ini IR IR IR IR EEN AA Seconds 05 BIOTRONIK excellence for life LV pacing threshold eee a 8 f i 2 pet ped d 4 eum E ES TIS uec 1 i u jA 3 1 SAN FE S 3 r cce 1 EAM i d ri MI dpt r Ed E hr hr mmm iS i a Tiber net E a m Br M l 4 F n du SUM A Dem i QUEE i dr L AJA ph peur a 23 BIOTRONIK excellence for life Idiosyncratic stuff the unknown unknowns G BIOTRONIK excellence for life 37yr old LQT mute deaf atient Name __ Bathe Wee Al U MN VF ON 300 ms FVT OFF ms VF VI OFF 400 ms herapy 200 500 bpm NID INITIAL 2 DEFIB 381 24 32 12 16 3 DEFIB 30J VT 16 16 4 DEFIB 30J 5 DEFIB 30J Sensitivity mV 0 3 6 DEFIB 30J ADDITIONAL VT DETECTION CRITERIA e STABILITY OFF rady Pacing is VWI Rate ppm 40 Mysteresis bpm OFF ONSET OFF EGM WIDTH OFF EGM Source HVA to HVB EOM Range nV 23 BIOTRONIK excellence for Device settings VF THERAPY 1 2 3 4 5 6 VF Therapy Status ON ON ON ON ON ON Energy J
3. R LR UE R 1 cm e hiii piita UE TE Tr ee T PH ke YET EA RTT TEE PUn Tp mmm 2 T 613 E ps oy F E bt z E TET M SETETE l EN Eu MT HA C TM Position 1 Surface ECG 0 5 mV em Position 2 V Sense Pace 12 mV cm 89 mV Position 3 Off Sweep Speed 25 0 mm sec gr 1 Li 1 u 1 8 a m EN LE l aaa ae BE geal a a kai diaz fa L sk i k r 4 s ri fete s vi ine 1 Li Li TE z mmu L As EM ee a ifa am an rea nmi amer price mide rrr nam oom eevee pM mod hui EI 1 Tag ng i La ram i k i 4 BEN rd Elf sade m ox nm oa a ER oce x E ku mu G w Ex nc kou s m m om m amp om L Pm xm i IM LAN rk GG RS k bebe pe a r za A tales For B meer raar GE EIE LT ise LIE ekir L r3 i Mi a E3224 de W a s as s a as Ba w lt al E IB ga Le f insan T L d mm x Had k j m K i
4. Uniform and identical Variable or minimal Uniform and distinctly to sinus difference from sinus different from sinus morphology morphology morphology Tal L L be W w w w ri 1 LX rud xTM r very easy Abrupt onset irregularly irregular AFib 100 100 100 100 100 100 100 100 100 100 95 100 SC 100 100 100 100 100 100 100 100 374 347 421 413 90 382 362 358 386 351 386 1456 394 354 335 390 378 335 284 378 382 39 R i Li IR m JR pid ii 8 EE IR RRR EER ER 16 17 18 19 20 21 22 23 24 Ww I RW J HA AA Ml Tre ATP ATP ATP ATP ATP ATP Q100 100 100 4 374 394 5 a74 382 74 354 487 1452 1491 1362 362 AR dt o et E cA NM S 77 SS To RGSS c Ad E Lack of appropriate Rx or unsuccessful Rx Loss of CRT pacing AF bad programming weird stuff Unsuccessful ATP MVT success Is it really VT Unsuccessful shocks Is the circuit OK what is the impedance More commonly seen at implantation 25 BIOTRONIK excellence for life I mplant induction amp failure stored Flectrogram Display 18 Jun 2004 09 09 Fib Detection msn WW AVR VA A if Defib Status RIR R rgy A Intervals U intervals d P d j tt I jp j dt
5. N x rd j IN IN li x I i L i l l 4 did id d Ad kul Li L En Bos ree S i a ee L A Dual Chamber Analyze atrial and ventricular rates gt Ventricular morphology AV interval Chamber of onset Response to Conducted VT SVT 1 1 AV VT 1 1 V AFib AFlu AFib AFlu conduction conduction Ventricular morphology Ventricular interval stability AV association Not so tough Sense Pace FS ro JEDE n Dui yee pot Markers Sweep Speed 25 mm s A Dual Chamber Ventricular morphology Ventricular interval Analyze atrial and ventricular rates Ventricular morphology Bit harder still AV interval Chamber of onset Response to Conducted VT 4 SVT 1 1 AV VT 1 1 VA AFib AFlu AFib AFlu conduction conduction AMS Entry Episode 1 of 2 stability li AV association Sense Pace AMS AS AS 5 AS ASAS ASAS AGAS ASAS AS AS 5 AS ASAS ASAS ASAS ASA J l 1 L 1 J L 3 4 l 7 1 1 I T r ri Markers BP BP BP BP BP BP VS VS VS VS VS VS Sweep Speed 3 di 304 50 509 501 H 501 500 501 53 50 az 3 p ome y A LUN im d 25 mm s 58 3 508 500 J 50 3 500 500 s
6. Flow of electricity current If you want current or water arriving at the end of the lead hosepipe you don t make holes in the hosepipe A lead with insulation damage a hosepipe with holes in it Low Impedance insulation damage lower current at tip 25 BIOTRONIK excellence for life Follow up Rubble Barney 177 Evia DR T 66001352 Mame Rubble Barney Last fallaw up 28 11 2011 D ate af implant 19 04 2010 Mode DDDR ADIKR Basic ppm 60 200 Pulse amplitude 3 0 3 0 Pulse width a v ms 0 4 0 4 Expected ERI 5 Y 11 EQS ERI BOS Q record available Mew episodes P R wave amplitude mi Threshold Lead impedance Ohms M 448 M 468 TrendView Pacing in 100 100 Atrial burden 95 Rate P 65 bpm Rate R 65 bpm AV del 125 ms Prag Perm Follow up in Parameters Tests E EE Recordings Gy Diagnostics Qmore n n E Preferences What has gone wrong with this device Signal Amplitude 12 9090000000000000000000000000000000000000000000000000000000000000000000 0 1 10 8 8 4 1 2 pese gt 12 Months Battery Voltage 320 1 30 e 28 dr a 25 BL a a CMM GE ERI 24 248 V 0 12 Months Pacing Lead Impedance Ventricie 200
7. JE IE f l 4 n s s s oro w Eik 1 a x ad 7 Alan 1 jil 1 AL Ld 1 B k nadat W rmi r m m m ra norm 1 Eu TT t L a LA s a amp Zum a LE il Ld us LO aa FELT bep a 4 md A f L a K 1 mre 1 k a das P 4 lt amp a Lcx E EET FEE KE k i 1 How bw F r wni m sk 8 m mw m m moll s L bhf Tort at r k base D r mt amp amp iia iE a a i a m E da ia ad nd k kn cea ER ET N ph mr ee na m w m m moe mad r nerep pf jrn ner pi EE E m pp ep Pi n serie errie n aie bese aes mu u ss cu m m a m LI 1 k EB L BG bg LI 1 F 1 im k sa s ma D kou 4 a i EE T ria Li P LI i Ei ie Ein membre pp i P mi m at sed ar on rd real usps
8. Conducted VT SVT 1 1 AV VT 1 1 VA AFib AFlu AFib AFIu conduction conduction dae Pietro iet kokk tendere eee stability IE AV association SenselPace AA H 1 H HH ST lt ASS AS 55 5 3455 5 5 55 AS ASS 5 SAS A iix ASS ASASS tts snk MEAS E LI E T LL L 1 ri j 4 L I i 4 TE eR 2 P E E E F F E E 320 293 207 270 308 309 265 262 262 273 363 2 27 7 1256 324 285 3B 3G 285 270 266 262 A Dual Chamber Ventricular morphology Ventricular interval Analyze atrial and ventricular rates Bit harder Ventricular morphology AV interval Chamber of onset Response to ATP Conducted VT 1 1 VA AFib AFlu AFib AF lu conduction conduction DO l v V oN f NM ed X X X X X X X X ay m m e NN N EE DN T T t T pO T T 39 48 31 3 28 34 28 28 22 stabilitv AV association T 574 586 574 578 543 359 367 1355 1355 1344 359 363 359 359 359 13 578 582 574 461 359 355 1355 ass 1352 359 355 1359 1359 363 359 363 R R R R R R R R R R R R R R R L LL L L l d
9. L L TIE AT i H Perrier ee eee m DII H D EET An OE Lg eie eee see owe m ere ere a eee n ass mn a D H arr one sais Bum ss S eee kaw mn mi sae U DE D ra amp 5 4 7 e 0 ti woe n us ds OO H oe me EE um A m a a eee amp 8 eee eee e r LE II T eee E a mwa WB E 8 8 E E sa EFFE EKKE REED r amp 8 w We pop B 8 H ee W Arcas Dia ar ie DN ies el U D se H 8 om AI d ow 5 H pati nnnm a 6 aa eee 1 H H B 3 AOE mwa H BUR EES GET G e g glee e 2 2 dawna s aa r H 8 di elm I N B n s E m ms 5 r E IKKKEPPPLOPITTERKI im Oe wv ae H H ER H ee ee ee D EI H
10. ie m F s rage o PN iL MEER mi TE EER BEE n haus vaas Lm mecnm ram k m uu n m EF Fa Pere PST sd n kw Ec 1 a E T am ra m m ee Fa iderri vr ka del Perre a harmas eee quar BH E b K h 1 Li a N LINIEN ES T j il 9 7 ri H rr x mt ap upi ba AT Pul nos dip fs ez 7 RE mmi rm DEPT ane ii h kil iL 1 a a a ER B bl 1 iz yu mal T aat 14 fits hg dd z beid Mil d H fe wmm wan fin 1 L cc LI pe m n eN bia 4 ET a 4 domom d j lt 4 a d u a E k LI LI k fered ref mmm d 1 T KEET T eke e e mar dx Li disais i i seu ois a Zr i Ri i 1 i riva TE LI f Tm u u a m fa T pa L mi m EE sere n oe Wu m zx uu aW m w ma R x im EN x rom 3 a
11. z Lu 4 a i T HE L re m mm Fromm L i LN Fa i L 4 s B had HE T u TR T 4 1 3 Enim 1 Hua fa Lda Bu u a T ek me Hi ad mE 1 s b TAR a uw um k m 3 mm mr om l mua aie sd me he M Es By ues hom mn FEE a h m ja oom o o omm E ne ze i bad 1 i ee a micas m anm aa ELI saman ad aar sau am nra DMs RENEE mu KEER ram EGER 1 sm DLS TTD TE LESE a mi Ia i i i ira iom B B La U i di k EE ET i a MM caah mns a sa lt ha nas M a a mua w u aasma py Max Bag l ka EA eee ee is d bal kal NEP EX L MERA Me ERE ence EFT ramen EE robe alea hid a dare E aa mock lt kim ne a a E Eod a Eu 4 Eu tal mami a lt k i L E u A w m fered m 8
12. H S3 d 3 amp B p H C n s d sels ese dae a H IE t D D OEE herr w mrnrnamanjjer IMEEM eli us dwase sg a w mw x h H a aus m ea E IN ia s M mor sonum m meom al aa B cvs drm m mo Ww m 8 w 8 858 in UE X M H 1 Enn aa asd ed ra 1 H 1 H 1 mn PEDEM LI n H wa W A ANTI H H H H H Ws wa N WB M H H kI H H 3 EO ee Se OK AE IE OES mom me m as x s mm 2 2 oot eee eee SR ER ete rarr 4 amp 4 XT serene h D wa H MECE Sie eae 8 ma jie aaa ETER H H D amp 6 aa sd B ka N Na ea TT H H ase eel es HIP far in on eee H H eee or s aat ga see se sie mM s m m m ps 5 C m T oe YL 4 f de ee hod si 88
13. ww 3 8 H D 4 2 ee tt Sa P SS N H H arse LCS s sis se a a E D sie sie wp a af ees For ror momo Ron n ng H H TP asse 3 3 8 6 6 F6 OE RR 8 18 e m m mwa aa eh IK eae H H AE 9 B P ETE OES se 68 4 5 8 8 3 X ay b h ed eee H Cae oe emis FAMA CMT EO JI e o x XLI ELE EE D M H b EE s am G 6 46 m w 6 te m w s ORC m m mm A m s m s H a H N a 9 B M EK S Ba dad OIE 3 sere m N x g D H 1 sm eae g s r sree Lo gelee CN D H i see Li DAL MAL ACTA IE JATI ole wpe g N E H EMI 8 d eK a ee eee a B U tar rit Pu ATI B a eee TA fill H D da s e te NC UE hae H H mnm T oo a i EN 81 Mee TE os H eee DD DD 0 EXE II m ee re
14. 20 30 30 30 30 30 Waveform BIPH BIPH Pathway ADB ADB ADB Reconfirm VF After Initial Charge YES THERAPY 1 2 3 4 5 6 FVT Therapy Status Initial Pulses R S1 Interval XRR 152 RAMP RR S2SN RAMP RR Interval Dec ms Sequences Smart Mode Energy J Waveform Pathway Anti Tachy Pacing Minimom Interval ms 200 VT THERAPY 1 aint coq 9 VT Therapy Status B NONE NONE NONE NONE NONE Therapy Type Initial f Pulses E R 81 Interval XRR JUR S1S2 RAMP RR idi SOSN RAMP RR 14 Interval Dec ms Sequences Smart Mode Energy J Waveform Pathway ANTI TACHY PACING THERAPY Anti Tachy Pacing Minimum Interval ms 200 Pulse Width ms 1 6 CV Delay ns nd Anplitude V 8 0 i p RE Pace Blanking ms 320 d e ds Le M TRO r BIOTRONIK excellence for life dCi sew BE s ER ind bol Daad dn mog peepee eee s guum m k wee ee hoo Doe LE a aaa B BIOTRONIK excellence for life da aa eed T L a a B a a ash a mua s N 1 i Committed Shock Therapy Comm
15. d Events U Events In IR R R IR IR R R R IR IR In In IR IR AAA L hh 17 stored Electrogram Display 18 Jun 2004 09 09 Fib Detection metit ab MA HH 3 FIFIFIFIFIFIRIEIRIRIEIEIERIR F D RR IR IR IR In in R R R R IR 24 x stored Electrogram Display 18 Jun 2004 09 09 830U L f ERA EE ED RAAR P PEE LEE ECDL AD HI E hu a E IR R IR IR R R R IR Vl IRI IR In In In In In In In IR in in ig iR IR FERA ir 4 25 26 ab 28 29 Seconds Vell Dt dm tt j d PEE dd 1531 11508 I I in nini IRI InIR EER IR IRIRIR avy MW TY ANJ Meme MA er 44 4 ue Ap Mi 31 jk 3h 34 36 Seconds E DN excellence for life 219 uw Less energy more success stored Electrogram Display 18 Jun 2004 09 24 RY cod to Can 5 2 m icm Defib Status A Intervals U Intervals i587 EI HI Hl l R HH H d H H d H H Events U Events E IRIRIRIR R IR R IR IR R R IR IR V Sense Pace i rit 13 5 m vicm L seca Stored Electrogram Display 1 New o 18 Jun 2004 09 24 Fib Detection RV coil to Can 5 2 mV cm BIERE IRIR IRIR IE IR IRIR IR Defib Status PIP AIR 6490 A Intervals U Intervals I j P1 P 4 1668 1969 Hood EE Events U Events RR in IR
16. 0 1800 100 st M D sss 0 12 Months L A kie a 1 z gt 0 wm G Capture Threshold Atrium c Ventricle 7 6 5 g o 2 pos O BIOTRONIK 0 12 ua Months excellence for life 23 BIOTRONIK excellence for life m e eee s i BIOTRONIK excellence for life BIOTRONIK excellence for life Oversensing Lead is bust Lead is not where it should be Something is not programmed correctly The lead is touching something it should not be Lead was the wrong lead for that patient Something from the outside world 25 BIOTRONIK excellence for life D LC 205 AS AS 203 293 I T 205 195 295 203 AS AS AS AS 229 205 _ 283 VF W 205 203 VS VE VF VF 619 205 203 200 B de A y s b I 7 ls AS AS N 205 203 283 205 203 mm Wo EE ER N 203 AS 205 VS 405 i n ii i 1 ER d 5 4 V M e Mir g e tee EE A1 Sense Pace 23 mm mV 28 9 my 2 Off _ Sweep Speed 25 0 mmus ELI Moo iw Tu dm r ME mac s N A WE HE EEE EE m wr ee NEE mS Jane air PR EE Ee ul I sk ELE GEEL IF FIF IF 8 E28 378 316 nn hhh hk
17. H 1 8010 OE LIR TA 2 D H H da 0 P TG aa ERETT LUE t FTT MH ove of eave m ese 8 18 im E see IPM H E WW RR dy er ig ee es gt eee KR Ra m m um m ee u M s Ra CTI Ee om H M CONCI LL NUR Kanna al EI eds eis ka a 5 4H WF 8 3 12 8 4 i o er on a amp 3 5 3 w S Rm FR US w 8 4 8 a s B H EE 1 1 5 MI M b N 8 3 3 1 se ee ese itti eorr EXE Cie tae lt de mm m AA AN E Ge mis as Hd a H N N is amp ae EC EA m um ME tag t H CBS DEC E N 4 CICER MEE RECTE je H H an a WD m le 4 1 4 8 5 8 3 5 4 N amp 8 9 mmm mm N a x A de tal errat T whens EE m H H
18. Troubleshooting Cardiac Rhythm Devices G BIOTRONIK excellence for life There are known knowns there are things we know we know We also know there are known unknowns that Is to say we know there are some things we do not KNOW But there are also unknown unknowns there are things we do not know we don t know A few pearis It is potentially very difficult There are idiosyncratic aspects of all device companies Finding out what these idiosyncrasies are Is tricky What happened or did not happen at implant is sometimes the source event Get as much information as you can Is your source reliable If it looks like a duck walks like a duck and quacks like a duck then we probably have to consider he possibility of us having a small aquatic bird on our hands unless it s a dragon doing an impersonation of a duck 25 BIOTRONIK excellence for life What do we need to troubleshoot LOC Oversensing am seeing too much Undersensing can t see Inappropriate therapy am delivering therapy when not required or a better alternative is available shocks for VT bad shocks for SVT really really bad RV pacing Lack of appropriate therapy Lack of ICD therapy slow VT Loss of CRT LOC bad programming 23 BIOTRONIK excellence for life e ee 9 6 oe o gt 5 e ee KEKEE 25 BIOTRONIK excellence for life E L
19. itted Shock Therapy 25 BIOTRONIK excellence for life Sometimes it is blindingly obvious 23 BIOTRONIK excellence for life Prevention Surgical options Cephalic Vs medial subclavian Appropriate programming fundamentals ATP SVT discrimination rates RV pacing reduction tracking rates Medical drug therapy is it appropriate did someone alter it Crystal balls Early detection Home Monitoring PRESCRIPTIONS M iz m yz Exi dele here an ounce of prevention 25 BIOTRONIK excellence for life
20. m as l soa 4 so 1 ps l soo 4 01 3 g 1 1 1 gl 1 A Dual Chamber Analyze atrial and ventricular rates ARV Ventricular morphology Ventricular interval Ventricular morphology AV interval Chamber of onset Response to stability AV association VT AFib AFlu I DUTEDTEETEETTYETETTI TTETTTYETETETTTTTTTEUNTTTETTETTTEE DI VT 1 1 VA conduction Conducted AFib AFlu SVT 1 1 AV conduction TTT Ba Trigger M v w w w w a use F F F IF F F F F F F 100 100 100 100 100 100 100 100 100 100 100 772 741 757 749 265 312 304 308 300 319 327 300 491 745 776 741 757 507 366 312 315 292 315 319 319 323 312 306 296 284 296 P IP IP R IR IR IR IR IR R R R EE EDE OER I ree eee Pe oor Fa ee LEZIJ E hd BE LLELE FYTFITIT TY FITTITITTITTITTTTITT p TTTTTTTTTTTTTTTTTT EEE POON SEET TEE Lin bed DS Spa HEDE quA Fere RIRIRIRIRIR S S 5 382 597 1608 1001 749 753 272 483 757 38 308 296 312 300 284 1141 753 745 753 I753 IP P IR R R IR IR R IR 5 17 l l 18 lici 19 mal l 20 l L 21 1 si L eee MAP 54 B Single Chamber _ 4 Ventricular electrogram morphology
21. rence from sinus different from sinus morphology morphology morphology Abrupt onset VT rregularly irreqular AFib December 2005 PACE Vol 28 A Dual Chamber Analyze atrial and ventricular rates Ventricular morphology AV interval Vontricular morphology Ventricular interval stability AV association Chamber of onset Response to ATP St JUDE MEDICAL Stored I wa ES KA Conducted VT SVT 1 1 AV VT 1 1 VA Patient Phot DR Model ial TS i Coo Summary Ent AFib AFlu AFib AFlu conduction canduction Position 1 Sense Pace 1 4 30 mV Position 2 V Sense Pace 12 5 mV cm 8 9 mW Sweep Speed 25 0 mm sec s 8 343 241 581 444 1589 577 581 433 292 296 585 677 577 1604 1585 54 413 307 E 460 433 460 425 452 444 460 7 49 l397 394 409 la3a2 las P P JA lw R LE wu n Eee X pp thr fp Trigger 5 5 5 s 5 5 5 L 8 L 35 265 2319 581 417 1685 507 jas4 304 558 462 296 292 569 522 ri 401 1405 1452 464 1421 409 421 468 479 421 1456 460 472 440 IR IR Lla se SIN ATA A Dual Chamber Analyze atrial and ventricular rates gt Easier Ventricular morphology Ventricular interval Ventricular morphology AV interval Chamber of onset Response to ATP
22. tal ma aor TET xm io samba Mma mu a anal wu HER EE iH ad 4 5 25 BIOTRONIK excellence for life 000000 0 iili Ms bu pp ea Le ma f FTI TITTTIJ ics da kh iai aor obit ee aide odi oido ic Ap 1 T TTI TTI Tric 73 85 86 85 88 66 32 52 82 74 40 50 67 11 U 555 555 551 551 551 551 559 563 559 570 563 563 563 563 5 555 555 281 273 281 270 551 551 281 273 281 281 281 281 281 289 563 281 281 281 281 289 IP P P P P P R R R R R F R IR IR R IR R IR R IR IR R Aa i lija li mi RR TIT FTA aan das salini lii ideas ide atl oia MARA BIT sc o ca baa B u ba E PA IF sl aa Lira a lara EN CO 11 12 13 14 15 16 BIOTRONIK excellence for life An Algorithm A Dual Chamber Analyze atrial and ventricular rates gt V Ventricular morphology Ventricular morphology Ventricular interval AV interval stability Chamber of onset AV association Response to ATP Conducted VT SVT 1 1 AV VT 1 1 AFib AFlu AFib AFlu conduction conduction B Single Chamber Ventricular electrogram morphology Uniform and identical Variable or minimal Uniform and distinctly to sinus diffe
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