Paediatric & end of life consideration Flashcards
Divulges ethical consideration surrounding EOL and practical concerns of implanting systems in the paediatric/growing patient. Currently weighted 1% in the CCDS exam.
True / False
1 in 5 palliative care patients will experience tachyarrhythmias in the last weeks of their life.
True.
True / False
In lieu of programming, ICD shock therapy can be terminated by placing a magnet over the device.
True.
True / False
End of life issues should be discussed at the time of implant.
True.
True / False
The following statement is a class I indication for end of life ICD consideration.
‘Patients with refractory HF symptoms, refractory sustained VA, or nearing the end of life from other illness, clinicians should discuss ICD shock deactivation and consider the patients’ goals and preferences’.
True.
True / False
The following statement is a class I indication for end of life ICD consideration.
‘ICD implantation or replacement, and during advance care planning, patients should be informed that their ICD shock therapy can be deactivated at any time if it is consistent with their goals and preferences’.
True.
True / False
Cardiac pacemakers are usually placed in the subpectoral region for paediatrics.
False.
Typically placed in the abdomen. Abdominal fat helps protect the pacemaker during falls, knocks and bumps that are part and parcel of childhood activity. Also less likely for twiddlers syndrome.
True / False
Most infants <15kg receive endocardial leads.
False.
Most receive epicardial leads as they’re easier to remove. Remember its likely the patient will have multiple revisions over their 60+ year lifetime.
True / False
Paediactric pacing is mainly performed in the setting of SND.
False.
It’s mainly performed in the setting of congenital or post-surgical complete heart block and less frequently in some surgical patients with sinus node dysfunction.
Epicardial leads in children are associated with
- Higher chronic stimulation threshold
- Higher lead failures and fractures
- Early depletion of battery life
Desipte this, list the two reasons why these leads are used.
- Preserves venous access for later in life
- Easier to remove leads
True / False
LV apical > RV apical as an epicardial pacing site for paediactrics.
True.
Less dyssnchrony, better haemodynamics, less progression to HF.
True / False
Paediatric venous obstruction post PPM lead implantation is related to the ratio of cross-sectional lead area to the body surface area at implantation.
True.
Why is it wise to always perform a venography in paediatric patients?
Large proportion of implant cases will present with congenital defects.
Thus venography will highlight potentially complex anatomy.
List 3 paediatric cardiac anatomy abnormalities which increase implant difficulty.
- Structural heart defects (TOF etc)
- surgical repairs (Fontan, Mustard, Senning)
- Synthetic septal patches (PFO closure)
- Atrial baffles
- Conduits
- Absence of appendages
- Obstructed venous channels
- Persistent left superior vena cava
- Extensive surgical fibrosis
True / False
Endocardial pacing is not an option in patients with single ventricles.
True.
Access is eliminated from the systemic veins after the extracardiac conduit Fontan procedure.
True / False
AV synchrony can add up to 15% to the paediatric cardiac output.
True.
True / False
Paediatrics have lower resting and peak heart rates than do adults.
False.
Typically much higher than adults.
True / False
Resting HR between 120-150bpm and peak rates >200bpm are not uncommon in paediatric patients.
True.
Majority of PPMs can pace at rates up to 180bpm.
True / False
Mismatch between peak HR and the generators ability to track this HR is of no concern in paediatrics.
False.
Limits to MTR can result in reduced exercise tolerance, pVO2 and anaerobic threshold.
True / False
Higher heart rates can have a negative effect on battery longevity.
True.
More stimulation = faster battery depletion.
True / False
Dual chamber pacemakers are generally reserved for patients >25Kg.
True.
Due to size constraints a single chamber PPM will likely be used in smaller patients.
List the 3 main implant approaches for abdominal pacemakers.
- Sternotomy
- Thoracotomy
- Subxiphoid approach
Which lead type is most likely to fail in paediatric patients?
- Conventional epicardial
- Steroid-eluting epicardial
- Steroid-eluting endocardial
- Conventional endocardial
Conventional epicardial leads.
No significant differences observed between the other 3 types.
Why are active fixation leads preferable to passive fixation in paediatrics.
Easier to remove / revise.
High likelihood of revision as ~50% of leads will have failed by the 15yr mark.
What is an atrial loop and why is it used when implanting paediatric endocardial ventricular leads?
Employing extra redundancy of the ventricular lead such that it forms a loop in the atrium.
This is to ensure better long term outcomes as the redundant slack will be used as the patient grows.
True / False
Paediatric patients comprise <1% of all PPM implants.
True.
Indeed paediatric implant centres may only implant circa 10 systems per year.
Describe what is meant by antibody positive vs. antibody negative for paediatric AVB.
- Antibody positive - Fetus develops AVB respondent to maternal antibodies / single stranded RNA crossing placenta and damaging conduction system.
- Antibody negative - Develops later in life, AVB is more likely to be a progressive disease.
True / False
Most common cause of AVB in congenital patients is respondent to damage from cardiac surgery.
True.
True / False
Paediatric incidence of AVB post surgery is <2%.
True.
True / False
Typically paediatric patients with transient AVB will recover <5 days.
False.
If truly transient, patient will most likely recover within 10 days. After 10 days PPM insertion is likely treatment.
True / False
After <7yrs of paediatric pacing, the following may be observed with epicardial implants.
- ~13% partial venous occlusion
- ~12% complete venous occlusion
False - these statistics are true of transvenous implants. Epicardial does not use venous access.
Bar-Cohen Y, Berul CI, Alexander ME, et al. Age, size, and lead factors alone do not predict venous obstruction in children and young adults with transvenous lead systems. J Cardiovasc Electrophysiol 2006.
True / False
Venous stenosis is always asymptomatic.
False.
May present with venous congestion and swelling of the ipsilateral arm.
True / False
Paed endocardial systems have similar complications as adults, however the incidence is much lower.
False - incidence of complication in paediatrics is far higher.
Smaller size, more complex anatomy, fewer numbers, less experienced operators, more active lifestyle are all recognised contributors.
True / False
VVIR is the most common pacing mode in small children.
True.
Children tolerate AV dyssnchrony better than adults and there’s a preference to implant the least amount of hardware possible early in a childs life. Thus single chamber devices are standard.
True / False
Unpaced postoperative heart block carries a high mortality in paediatric patients.
True.
Why should RVp should be minimised in paediatrics and how can it be achieved in SR systems?
Higher rates = More RVp over time. This is potentially determinental as per MOST study findings.
Higher pacing % could increase risk of pacemaker syndrome and ventricular dysfunction. Thus program a lower HR and/or remove rate response function to encourate intrinsic conduction. Important to balance HR and respondent exercise tolerance with Vp%.
List 3 reasons why CRT outcomes in paediatrics poor.
- Paeds rarely present with LBBB and QRS >150ms, which are markers of CRT success
- CRT in adults is mainly ischemic based, in paeds its congenital or progressive cardiomyopathies
- CRT isn’t shown to benefit the failing RV, which is the most likely ventricle to fail in congenital scenarios
True / False
Paediatric patients most likely to benefit from CRT are those with impaired LV function who are being paced from the RV (Thus presenting with LBBB morphology on ECG).
True.
Yes / No
Can patients/guardians request discontinuation of tachy/brady therapy, even when not terminally ill?
Yes.
It is unethical to provide any treatment against a persons will.
True / False
All patients are asked about their wishes to cease device therapy at the time of implantation.
False.
Only a small minority of patients are asked this question, when in fact all patients should be asked to ensure appropriate action is taken should the need arise.
What should be ascertained when any request to end critical treatment is requested.
Cognitive competence and the ability to comprehend the consequences of changing device settings.
E.g. The difference between ending tachycardia therapy and/or pacing therapy in a dependent patient.
True / False
Withdrawal of Tach/Brady therapy is not akin to withdrawal of mechanical ventilators, heamodialysis or other life support machines and should never be performed.
False.
True / False
Withdrawal of Tach/Brady therapy is likened to assisted dying, analogous to voluntary euthanasia.
False.
True / False
A person’s underlying condition is deemed the cause of death following treatment withdrawl.
True.
True / False
It is unethical to withdraw treatment that becomes part of the patients self - I.e. organ transplant.
True.
This does not apply cardiac devices.
True / False
From an ethical and legal standpoint, the following statement is true.
‘Refusing cardiac device implant and withdrawal of cardiac device therapy are one and the same’.
True.
What should be done if personal and professional opinions differ between clinician and patient with respect to withdrawal of therapy?
HRS guidelines state clinicians are obligated to arrange for alternative provision of care in cases of conscientious objection that cannot be resolved.
True / False
Withdrawing bradycardia support is unlikely to result in instantaneous death but rather symptoms respondent to inadequate cardiac output like dizziness and syncope.
True.
True / False
In patients with a do not resuscitate order in force, ICD deactivation should be seriously considered.
True.
True / False
An active pacemaker will not affect the timing or circumstances of death as a patient typically becomes acidotic before cardiac arrest, rendering the pacemaker ineffective.
True.
True / False
Cardiac device deactivation is an extension of patients’ self-determination regarding their own treatment.
True.
