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IBHRE® > Surgical technique & complication > Flashcards

Surgical technique & complication Flashcards

Provides an overview of how generators / leads are implanted and the respondent complications that can arise. Currently weighted 9% in the CCDS exam.

1
Q

Patients anti-coagulated with Warfarin should ideally present with an INR below what?

A

<1.5

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2
Q

Restart of heparin within 24hrs post implant represents what percentage risk increase of haematoma vs unanticoagulated patients?

A

20% risk = 5x the risk of normal.

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3
Q

Patients with an existing CRM device have what % prevalence of lateral subclavian vein occlusion?

A

25%.

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4
Q

True / False

Pacemaker leads can be placed through mechanical valves.

A

False.

Mechanical valves are contraindicated. Bioprosthetic are not.

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5
Q

List the 3 most commonly used access veins during device implantation.

A
  1. Cephalic
  2. Subclavian
  3. Axillary
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6
Q

List two pros and two cons of the Cephalic access.

A

Pros = Direct vision & fewer potential complications.

Cons = Small & clean dissection.

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7
Q

List two pros and and two cons of the Axillary access.

A

Pros = Fewer complications & large vessle can support multiple leads.

Cons = Requires Fluro & technically difficult.

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8
Q

List two pros and and two cons of the Subclavian access.

A

Pros = Easy access & Large vessle can support multiple leads.

Cons = Requires Fluro & risk of Pneu/Haemothorax (also crush risk post implant).

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9
Q

List two reasons why implanters prolapse the RV lead and don’t directly push the RV lead into the RV.

A
  1. Reduces likelihood of CS cannulation
  2. Reduces risk of perforation
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10
Q

True / False

RA leads are normally fixated to the atrial free wall.

A

False.

RA leads are normally placed in the Appendage.

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11
Q

What site in the RA may be more prone to phrenic stimulation?

A

Free wall positions.

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12
Q

List 3 types of LV pacing.

A
  1. Transvenous via Coronary Sinus
  2. Epicardial
  3. Endocardial - best haemodynamics, however chronic antiocoagulation reqiured
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13
Q

Where does the CS drain?

A

Posteroseptum of RA.

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14
Q

List the CS veins in order from Proximal to Distal.

A
  1. Middle cardiac vein
  2. Posterior
  3. Posterolateral
  4. Lateral
  5. Anterolateral
  6. Anteroventricular
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15
Q

60% of leads in MCV can be advanced to where?

A

Posterolateral free wall.

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16
Q

Typically which two radiographic views are used to visualise the CS?

A

RAO & LAO.

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17
Q

Order the target veins for CRT in terms of preference.

A
  1. Lateral
  2. Posterolateral
  3. Posterior
  4. Middle cardiac vein
  5. Great cardiac vein
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18
Q

True / False

Greater RV to LV lead tip separation typically results in improved clinical outcome.

A

True.

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19
Q

Is lead I positive or negative with RV pacing?

A

Positive.

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20
Q

Is lead I positive or negative with LV pacing?

A

Negative.

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21
Q

Is lead III positive or negative with LV pacing?

A

Positive.

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22
Q

Is lead III positive or negative with RV pacing?

A

Negative.

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23
Q

BiV pacing typically produces what axis?

A

Right Superior.

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24
Q

Loss of a Q wave in I during pacing typically represents what?

A

Loss of BiV pacing.

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25
Q

When testing unipolar leads - which clips are attached where?

A

Anode = Red Clip = Tissue.

Cathode = Black Clip = Distal Lead electrode (Equates to lead tip electrode).

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26
Q

Phrenic Nerve Stimulation at low/normal output is a potential indicator of what?

A

RV perforation.

Check for negative injury current.

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27
Q

Tissue fibrosis improves lead stability however negatively influences generator current drain - explain why?

A

Tissue fibrosis increases effective distal electrode size = Respondent increase in current drain.

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28
Q

Yes / No

Can you see a current of injury when implanting passive leads?

A

Yes.

Injury current is representative of pressure on the myocardium.

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29
Q

True / False

‘Threshold can increase immediately following deployment of passive fixation leads before lowering some minutes later’

A

False.

This is true of active fixation leads only. Helix deployed = increased threshold for some minutes. This is not typically seen in passive fixation leads.

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30
Q

Describe common threshold characteristics of non-steroid eluting leads from implant to 6wks follow up.

A

Higher thresholds for first 24hrs and rising over 7 days. Threshold stabilises 6wks post implant. Final threshold normally higher than at implant but lower than highest peak.

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31
Q

Describe common threshold characteristics of steroid eluting leads from implant to 6wks follow up.

A

Steroid eluting leads rarely exhibit marked changes in threshold over time.

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32
Q

What is the implant success rate for MICRA?

A

99.2%.

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33
Q

What are the MICRA tines made of?

A

Nitinol.

34
Q

Describe satisfactory R-wave / Threshold / Impedance values of MICRA systems.

A
  1. R-wave > 5mV
  2. Threshold <1.0V @ 0.24ms
  3. Impedance 400-1500ohms
35
Q

True / False

RVOT pacing leads are approximately the same level as appendage on radiograph.

A

True.

36
Q

When placing a single coil RV lead, does site impact Defib Thresholds and/or sensing?

A

No.

Typically same thresholds and sensing regardless of RV lead position.

37
Q

Define the difference between complete & clinical lead removal success.

A

Complete = All lead material removed.

Clinical = Some lead material left behind but not negatively impacting clinical outcome.

38
Q

Success rate of lead extraction is __%.

A

90%.

39
Q

If the lead pin isn’t fully inserted into the header, what two common outcomes can occur?

A
  1. Sensing artefact
  2. Failure to pace

Lead impedance fluctuations alone aren’t enough to detect this issue.

40
Q

List 4 contraindications to transvenous lead placement.

A
  1. Tricuspid valve abnormalities
  2. Central venous obstruction
  3. Congenital heart disease
  4. Technical issues
41
Q

True / False

Pacemaker leads can’t be placed through bioprosthetic valves.

A

False.

Pacemaker leads can be placed through bioprosthetic leads but not mechanical ones.

42
Q

Why is a greater RV to LV lead tip separation desirable with respect to CRT outcome?

A

Greater separation = greater capture field.

Thus more myocardium is activated leading to improved haemodynamics.

43
Q

Negative injury current is an potential indicator for what?

A

RV perforation.

44
Q

How is MICRA deployment defined?

A

When 2 of 4 tines are attached.

45
Q

List 5 indications for lead extraction.

A
  1. Infection
  2. Malfunction
  3. Thrombosis / Venous Stenosis
  4. Lead Interaction
  5. Requirement for MRI
46
Q

Name two leads currently on recall.

A
  1. Sprint Fidelis
  2. Riata
47
Q

List 6 class I removal indications for infection.

A
  1. Endocarditis
  2. Sepsis
  3. Pocket abscess
  4. Device erosion
  5. Skin adherence
  6. Occult gram-positive bacteremia
48
Q

Device explant for chronic pain at surgical site is which indication classification?

A

Class IIa

49
Q

List 3 class I removal indications for thrombosis & stenosis.

A
  1. Thrombus on lead or fragment
  2. Subclavian or SVC occlusion
  3. Stent deployment to vein with lead
50
Q

List 3 Class I removal indications for functional leads.

A
  1. Life threatening arrhythmias caused by leads
  2. Immediate threat if leads left in place (fracture and protrusion)
  3. Leads interfere with other leads
51
Q

List 3 Class I removal indications for non-functional leads.

A
  1. Life threatening arrhythmias caused by leads
  2. Immediate threat if leads left in place (fracture and protrusion)
  3. Leads interfere with other leads
52
Q

True / False

Generator erosion is considered an indolent infection that almost always requires extraction.

A

True.

53
Q

List two common predisposing factors for system infection.

A
  1. Diabetes mellitus
  2. Post operative haematoma
54
Q

Which bacterium is most commonly causative of acute site infection?

A

Staphylococcus Aureus.

Pussy and manifests within first few weeks.

55
Q

Which bacterium is most commonly causative of chronic site infection?

A

Staphylococcus Epidermis.

Manifests months/years after implantation.

56
Q

What percentage of acute infections complicate new implants?

A

33-50%.

57
Q

What should be assumed with bacteraemia without localising signs?

A

Endocarditis.

58
Q

Does lead endocarditis typically occur before or after pocket infection?

A

Normally post pocket infection.

59
Q

Is endocarditis normally introduced at implant or secondary to transient bacteraemia?

A

Secondary to transient bacteraemia, typically from an unidentified source.

60
Q

How do you diagnose lead endocarditis?

A

Vegetation on lead via ECHO in presence of other signs of infection.

61
Q

Occult gram positive bacteraemia is which indication class for removal?

A

Class I indication.

62
Q

Occult gram negative bacteraemia is which indication class for removal?

A

Class IIa indication.

63
Q

How long should one wait to confirm negative infection status following gen removal and antibiotics?

A

Between 3 to 10 days.

64
Q

When should prophylactic antibiotic concentration be highest in tissue?

A

30-60mins prior to procedure.

65
Q

Yes / No

Is there data to support giving antibiotics for more than 24hrs after implantation?

A

No.

66
Q

The following are all deleterious effects of which RV lead pacing site?

  • LV mechanical Dyssnchrony
  • Heart Failure
  • LV remodelling
  • AF & Increased Atrial Size
  • Mitral Regurgitation
A

RV Apex.

67
Q

During implant, ST segment elevation is representative of what?

A

Current of injury.

Proportional to adhesion of lead to the myocardium. Typically the greater the injury current = more stability and less likelihood of dislodgement.

68
Q

How does one assess whether the lead has enough slack?

A

During Fluro - ask the patient to inspire deeply.

This lowers the diaphragm and straightens the lead, thus allowing the assessment of slack.

69
Q

Why should one pace both the A and V leads at max output during implant?

A

To rule out diaphragmatic capture.

70
Q

A notched P-wave is seen on ECG lead II, what does this suggest and what are its implications for lead placement?

A

A notched P-wave in lead II alludes to Inter-Atrial conduction delay and respondent atrial dyssynchrony.

Atrial lead should be placed on the high/mid atrial septum or close to Cs Os. This will restore simultaneous contraction of the atria.

71
Q

How would you test for phrenic nerve stimulation during an implant?

A

Pace at max output possible via PSA / Device and do deep breathing manoeuvres. Look and feel for stimulation.

72
Q

What is the incidence of pocket infection?

A

<2%.

73
Q

Yes / No

During the implant the Dr asks if you see injury current - what do you say?

A

Yes.

There is marked ‘ST Segment’ elevation post impulse on the RV channel. This is a good predictor of lead stability.

74
Q

Yes / No

During the implant the Dr asks if you see injury current on both channels - what do you say?

A

Yes.

Marked ‘ST Segment’ elevation is visibile on both A and V channels.

75
Q

Outline potential cause and cures of right-sided abdominal jumping one day post CRT implant.

A

Most likely atrial lead capturing phrenic nerve.

Lower atrial output if possible or reposition atrial lead.

76
Q

Outline potential cause and cures of left-sided abdominal jumping one day post CRT implant.

A

Most likely LV capture of the phrenic nerve causing diaphragmatic capture.

Lower LV output if possible or program different bipolar configuration.

77
Q

List 5 considerations that must be realised during box change procedure.

A
  1. Check underlying rhythm
  2. Turn rate response off
  3. Turn ICD detection off
  4. Check lead connectors - IS1, DF1, DF4, IS4 etc.
  5. Check lead polarity - Unipolar pacing will cease when device leaves pocket.
78
Q

Patient presents with the following 6hrs post PPM implant, what is the appropriate course of action?

‘Clear chest sounds, No pneumothorax via X-ray, BP = 100/70mmHg, DDD 70 shows seq AVp’

  1. Repeat X-ray
  2. Cardiac Echo
  3. Administer furosemide
  4. Administer beta blocker
A

2 - Cardiac Echo.

It sounds likely the lead has perforated which could lead to tamponade. Echo is more precise than X-ray to highlight this.

79
Q

Which tissue plane shows the appropriate implant level for most patients?

A

C - Below the fat layer yet above the muscle.

D represents submuscular implants, which are rarer and predominantly for cosmetic reasons.

80
Q

True / False

The following patient requires a transvenous DR PPM system.

‘16yr old female, Syncope due to CHB, Fontan procedure’

A

False.

Pacing indications are met, however fontan procedure contraindicates transvenous approach. Thus an epicardial DR PPM.

IBHRE® (24 decks)

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