Time Stamps

  • 01:13 Pearl 1: Should we approach syncope history differently in our patients with pacemakers and ICDs?
  • 06:31 Pearl 2: Considerations for patients with implantable devices before surgery.
  • 12:26 Pearl 3: Considerations for patients with implantable devices before MRI.
  • 14:45 Pearl 4: Anticoagulation in patients undergoing pacemaker or ICD procedures. 
  • 18:17 Timestamp 5: Emerging cardiac device technology and how they might look different on EKG or chest x-ray. 

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Show Notes

Pearl 1: Should we approach syncope differently in our patients with pacemakers and ICDs?

Pearl 2: What do you do when a patient with an implantable device is undergoing surgery? 

  • Patients with pacemakers or ICDs undergoing surgery
    • May need  place magnet vs. device reprogramming
      • Reduces risks of procedure-related complications from device malfunctioning
        • Potential risks:
          • Signal from electrocautery devices can:
            • Interfere with pacemaker/ICD function and lead to the pacemaker/ICD mistakenly interpreting signals
              • Particularly high risk in surgery performed superior to the iliac crests (i.e., closer to heart) 
              • Can mistakenly pace
                • Potentially life-threatening tachyarrhythmia
              • Can mistakenly inhibit pacing
                • Potentially symptomatic or hemodynamically unstable bradyarrhythmia
      • How does magnet work in pacemakers?
      • How does magnet work in ICDs?
        • Disables shock therapies only in ICD
        • If the patient also has a pacemaker indication
          • Needs some additional programming since the ICD will still pace AND sense 
            • We don’t want the ICD to sense the cautery mistakenly as signal from the heart!

Pearl 3: What do you do when a patient with an implantable device is undergoing a magnetic resonance imaging (MRI) study?

  • Nearly all patients with pacemakers and ICDs can safely undergoing MRI!
    • As long as certain safety protocols are followed 
      • Cardiology and Radiology work together to make sure the study is performed safely
        • Make sure to inform Radiology that your patient has as implantable device
        • Reach out to Cardiology for help
    • Safety measures include:  
      • Limiting scans to 1.5 Tesla MRI machines
      • Device reprogramming for the duration of the MRI study
      • Pre- and post-study device interrogations

Pearl 4: What anticoagulation should be used for implantable device placement?

Pearl 5: What are the newer implantable cardiac devices?

  • LEADLESS PACEMAKERS
    • Mechanism: Single chamber pacing
      • Implanted directly into the right ventricle (via femoral vein) without the generator and leads of a traditional pacemaker
    • Benefits:
      • Small device
      • No need for chest incision
      • No risk of pocket hematoma
      • Limited risk of infection
      • No risk of lead fracture 
    • Limitations:
      • Single chamber pacing 
        • Not a good option for a patient with sinus node dysfunction
          • However, some newer models are able to promote AV synchrony and atrial leadless devices are under development!
      • Do not defibrillate 
  • CONDUCTION SYSTEM PACING (CSP)
    • Mechanism:
      • Delivers a stimulus directly to the His bundle or left bundle (as opposed to delivering stimulus to cardiac myocytes near the coronary sinus) 
        • Preserves normal cardiac electrophysiology!
      • Used in treating arrhythmias and heart failure
  • CARDIAC CONTRACTILIY MODULATION DEVICES (CCM)
    • Mechanism
      • Delivers electrical signals to the right ventricular septal wall during its refractory period
        • Does NOT cause a new contraction (signal is delivered during the refractory period!)
        • Instead…the signal causes changes in gene transcription which leads to changes LV contractility over time! 
      • Used in treating heart failure 

 

Transcript

Dr. Shreya Trivedi: Hi everyone! Welcome to Core IM. I am Dr. Shreya Trivedi. Today I am joined by the lovely Dr. Aaron Dunn, soon to be a nocturnist somewhere in this country, and whose voice you might remember from our 5 Pearls episode on Pacemakers and ICDs.

Dr. Aaron Dunn: Hey everyone! I’m happy to be back. If you feel like you didn’t get enough from our first episode on Pacemakers and ICDs, we are coming at you with round two! 

Dr. Shreya Trivedi: Yeah! These are questions that come up all the time but didn’t make it into the original 5 Pearls on implantable cardiac devices. Let’s get started with the mini-pearls that we’ll be covering in rapid fire in this episode. Test yourself by pausing after each of the 5 questions. 

Dr. Aaron Dunn: Pearl 1 – Framework for Syncope. Should we approach syncope history differently in our patients with pacemakers and ICDs?

Dr. Shreya Trivedi: Pearl 2 – Considerations for patients with implantable devices before surgery.

Dr. Aaron Dunn: Pearl 3 – Considerations for patients with implantable devices before MRI.

Dr. Shreya Trivedi: Pearl 4 – Anticoagulation in patients undergoing pacemaker or ICD procedures. 

Dr. Aaron Dunn: Pearl 5 – Emerging cardiac device technology and how they might look different on EKG or chest x-ray. 

PEARL 1

Dr. Shreya Trivedi: Alright, let’s get started. Starting with syncope. Here, we are talking about someone having a brief decrease in blood pressure leading to inadequate perfusion of the brain, leading to a loss of consciousness. So Aaron, let’s say you have a new patient coming in with syncope. Probably happens once a week or so, or more. What is your general framework for this?

Dr. Aaron Dunn: Yeah, one of the things I have learned is to think about syncope in 3 big buckets. Number 1 – reflex syncope, which usually is vasovagal. Number 2 – orthostatic, whether it’s the autonomic nervous system, hypovolemia, or a medication side effect. And number 3 is cardiogenic syncope. Which can be due to abnormal heart rhythms or to valvular disease. And it’s also important to rule out common mimics. Things like hypoglycemia or seizures. And there’s a great Clinical Problem Solvers framework that you can check out as well!

Dr. Shreya Trivedi: Wow! Yeah, I really like that one too. We also sat down with Dr. Andy Locke, and electrophysiologist at Beth Israel Deaconess Medical Center, and asked him, his approach to history-taking for syncope and if it changes if the patient has an implantable device.

Dr. Andy Locke: I think people think that cardiologists or electrophysiologists do something special with the syncope evaluation, and like we really don’t. So, so essentially taking a step back, away from the fact that they have a device. Really, whether they have a device or not, the initial evaluation is the same, the clinical evaluation. So, when you see a patient with syncope, you want to go talk to them and get a clinical history. Because the history for syncope is 95% of the evaluation.

Dr. Aaron Dunn: Yeah! I always feel like such a good medicine doctor when I can uncover that critical piece of someone’s story.

Dr. Shreya Trivedi: Same, same, gives me so much life.

Dr. Andy Locke: So when we see patients for syncope, we want to know were there prodromal symptoms. Did they feel lightheaded? Did they, did they feel something coming on? Did they feel a wave of, of, of diaphoresis? Of nausea? Were they eating? Were they going to the bathroom in the middle of the night? 

Dr. Shreya Trivedi: Yep, for example any mention of a toilet, for example, leading up to syncope, I’m almost always thinking vasovagal. Versus something like, exertional syncope. That red flag has a pretty small differential. Arrhythmias, outflow obstruction, HOCM, aortic stenosis, PE, pulmonary hypertension. They’re all things that come to mind for an exertional syncope history. 

Dr. Aaron Dunn: Right, that context is so important. And as humble as Dr. Locke is, that EPs don’t do anything differently, he did bring up a part of the history I did not appreciate as much.

Dr. Andy Locke: And then what’s key and what people forget about is how did they feel when they woke up? So if someone felt totally washed out and exhausted for minutes to even an hour, two hours, or three hours after, that’s almost certainly a vasovagal episode. Those episodes are not life threatening arrhythmias. Arrhythmia, clinical history of arrhythmia is “I was feeling fine.” Maybe I felt a little light headed or maybe I felt nothing, and boom, I was gone. I woke up 30 seconds later, 10 minutes later, an hour later, and I felt completely normal. And that’s the people you should be worrying about. The people that had abrupt onset syncope, with no symptoms following the event. Think brady or tachyarrhythmia as an etiology.

Dr. Aaron Dunn: Wow, I don’t know if I paid enough attention to how a patient felt when they woke up. If they felt exhausted or if they felt totally normal. 

Dr. Shreya Trivedi: Yeah! Same! I feel like I always learned to pay attention to the prodromal symptoms. If someone had them, then it points towards more vasovagal or orthostasis, but if someone didn’t have those symptoms before they syncopized, it was more of that lights out syncope. It was more concerning for an arrhythmia. But Dr. Locke clarified that those prodromal symptoms pointing to one bucket is actually not a hard and fast rule, and that’s especially true in our more older and frail patients. 

Dr. Andy Locke: Now, what is important to remember is leading up to when someone syncopizes, if it is from an arrhythmia, you can feel palpitations, you can feel nausea, you can feel diaphoresis. You can feel those kind of more reflex syncope symptoms. Those prodromal symptoms that we kind of really focus on. So in that sense, it can be a little difficult to parse out. But almost always when they wake up, that’s the key, asking them, how did you feel when you came to? If patients are confused, if they lost bowel or bladder, uh, you know, they were incontinent, um, and if the confusion last hours, you know, thinking about seizure. If they felt totally washed out afterwards exhausted for hours to even up to a day, that’s more consistent with reflex syncope, vasovagal syncope, which is the most common form of that. And then if they woke up and they felt kind of fine, they were scared and a little confused, but they, but they felt okay. They were able to interact with medical staff. That’s when you want to think that an arrhythmia had, had a role.

Dr. Aaron Dunn: Yep! Again reiterates the big takeaway for me that it’s how someone feels AFTER passing out that can really help distinguish between that benign, vasovagal episode and a life-threatening arrhythmia. 

Dr. Shreya Trivedi: Yeah and then for me, the takeaway with this one is those prodromal symptoms can be present in cardiac syncope also. And actually after talking to Dr. Locke, I went back and looked at the JAMA Rational Clinical Examination series syncope article, and the likelihood ratio for things like pallor, blurry vision, awareness of being faint, diaphoresis, nausea are, actually, those likelihood ratios are not overwhelming. Some cross 1 and are not as helpful in differentiating cardiac syncope versus other causes. 

PEARL 2

Dr. Aaron Dunn: So let’s dive deeper into pacemakers and ICDs, and really common questions that come up. 

Dr. Shreya Trivedi: Yep, next up is a situation we’ve all had. A patient has a pacemaker or ICD and is going for a surgery or going down for an MRI. And you get that MRI questionnaire. So how do we triage these patients with an implantable device? Let’s first start with surgery in this mini pearl and then tackle MRI in the next mini pearl.

Dr. Andy Locke: So before surgery and before MRI, these are good times to contact us. Um, so, what, what you have to think about in these situations is you want to avoid a situation where a patient gets an inappropriate shock if they have an ICD, and you want to make sure that someone who needs pacing is getting paced and it’s uninterrupted during the time of surgery or the MRI, okay? Surgery is a little bit easier for us. So, so if a surgery is below the iliac crest, you typically do not need to involve us. Okay? If it’s above that. Well, you should involve us uh. Often what is what we’re able to do, you can put what’s called a magnet on a device pacemakers when they see a magnet, no matter the manufacturer, change to an asynchronous mode of pacing, which means I will pace, but I am not listening to anything around me. I am not doing anything in response to anything. I’m, I don’t care. I’m going to pace no matter what I see, because I’m going to make sure that the patient’s getting paced. 

Dr. Aaron Dunn: Okay, so surgery inferior to the iliac crest does NOT usually require any changes to the pacemaker, but for surgery superior to the iliac crest, we should get cardiology involved so that they can place a magnet. 

Dr. Shreya Trivedi: Yeah, and when that magnet gets placed on the pacemaker, it’s going to change the mode so that it keeps the pacemaker pacing but NOT sensing. And this is to prevent the pacemaker from sensing any cautery and reacting to that, and that would really be bad news.

Dr. Aaron Dunn: Yeah, that would be bad. I kind of think about the asynchronous pacing mode like those professional athletes or musicians who are in a state of “flow” and just do without reacting to the outside world.

Dr. Shreya Trivedi: Man, Aaron, I love that analogy. I feel like that’s my dream as a doctor, to just be in this flow state and not react to the many curveballs of the day. Yeah, like in my best states, I’m like, yes, achieving! But, anyways, as we are talking about magnets turning off the pacemaker’s ability to sense, I am wondering if that might bring up issues, too? 

Dr. Andy Locke: The only time you run into issues with that is if someone’s intrinsic heart rate is faster than the magnet rate. Um, so if you, if someone has intermittent heart block, for example, and they’re going to go for surgery, and you want to make sure they don’t have heart block during surgery. If you’re going to set an asynchronous mode, someone may be conducting normally and you’re going to pace on top of that. That could be a problem. You could get what we learned about in med school known as an R and T response. An R and T responses when you are depolarizing the heart during repolarization phase during the during the T wave. An R being a QRS and a T being the T wave. And that can cause torsades, um, you know, polymorphic VT, and that’s bad. So we don’t want to do that. So you want to make sure when you’re doing an asynchronous mode that you’re safely programming it. So you’re trying to be safe for the patient and making sure they get paced when they need to, but you’re not making a dangerous situation.

Dr. Shreya Trivedi: I guess the good thing here is that cardiology can be really helpful in helping us think about the underlying rhythm, such as intermittent heart block. And if we can just put a magnet for asynchronous pacing or if we need to program the pacemaker in another way to prevent this complication during surgeries above the illicit crest.

Dr. Aaron Dunn: So that’s pacemakers, but what about patients undergoing surgery who have defibrillators or ICDs? How’s that different?

Dr. Shreya Trivedi: Yeah and before we get into that, I think what might be helpful is two quick space-based repetition points from our original episode on the difference btw pacemaker and ICD. So first, we typically we think of pacemakers as treating slow rhythms and ICDs as treating fast, dangerous rhythms. And ICD do so by either delivering a shock or anti-tachycardia pacing. And then the second quick point is that ICDs can do everything a pacemaker can. So ICDs can pace, too! And this is important because magnets do something different to ICDs then they do to pacemakers.

Dr. Andy Locke: With defibrillators, magnet modes disable ICD therapy, but they don’t affect pacing. So if someone’s cauterizing right around, you know, the thyroid or the lung or something there, if an ICD sees that it will shock a patient because it thinks it’s VT. If you disable that great, you’re not going to get a shock, but if a person needs pacing, you are inhibiting them. So if someone has a defibrillator, and they’re going for surgery, but say they also have a pacing indication instead of a magnet, we’re going to have to physically go there and program the device because a magnet will only shut off the ICD therapy.

Dr. Aaron Dunn: Okay, so if you put a magnet on an ICD, it only turns off the shocks. But the pacemaker part of the ICD will still be sensing and pacing, and that might cause a problem for someone who is dependent on the pacemaker, if it thinks the cautery is actually an electrical signal from the heart. 

Dr. Shreya Trivedi: Yeah! So here, our friendly cardiologist is going to need to do some additional reprogramming with the ICD prior to surgery. Alright, so Aaron. I think this could be a good place to pause and recap this quick pearl on cardiac devices before surgery? 

Dr. Aaron Dunn: Yeah! When you have a patient with a pacemaker or ICD who needs surgery, first think: is the surgery above or below the iliac crest? If it’s below, they are likely in the clear. But if it’s above the iliac crest, cardiology should usually be involved. In the case of a pacemaker, they can place a magnet to change it into asynchronous pacing mode. And for an ICD, they may need to do additional reprogramming. 

PEARL 3

Dr. Shreya Trivedi: Alright, Aaron! I feel like, now, I have a good sense of how to triage prior to surgery based on if its have pacemaker or ICD, particularly if it’s above or below the iliac crest. What about MRI? And what do we do about our patients who need to go down for an MRI? 

Dr. Andy Locke: MRI Is a little tricky because MRI, these devices, the newer devices are now MRI conditional or compatible, but they there are a lot of devices out there that are not FDA approves. So first, the first thing I’ll just take a step back. It is safe for patients who have a cardiac device to get an MRI under certain, under almost every condition, but with the proper monitoring. Okay. So, so for a patient to get one of these devices and to come in and, and, you know, during an interview, they say, you know, doc, my, my cardiologist told me I can’t get an MRI. That’s typically not true. Assuming you have the proper monitoring, you have to set up these, you know, the right pacing modes and all these things. It takes a lot of resources. So, so we need to be involved. We need to make some programming changes. We need radiology to be okay with it. Um, but it’s, uh, it’s doable.

Dr. Aaron Dunn: That’s definitely a learning point for me. I had always thought there were two buckets: MRI compatible pacemakers and MRI incompatible pacemakers, but it actually sounds like nearly all pacemakers are okay for MRI, as long as certain steps are taken for programming and monitoring during the MRI. 

Dr. Shreya Trivedi: Yeah! And maybe another way to think about is there, there are devices that are intrinsically compatible, and then the other bucket is compatible after modification.

Dr. Aaron Dunn: Oo, I like that! And just to be explicit, MRI, like cautery in surgery, can interfere with the normal function of a pacemaker. And also, it can even dislodge the leads or heat them up and burn the local myocardium if the right protocols are not in place, which sounds really scary! 

Dr. Shreya Trivedi: Yeah, that is something we definitely want to avoid. The biggest blessing of all of this is that hospitals and clinics of have specific protocols to reduce the risk. Okay. So, to sum up, I think the big takeaway here is that patients with pacemakers and ICDs can undergo an MRI. Cardiology will likely need to be involved to help reprogram the device before the scan. Monitor the patient during the scan depending on what type of device and leads the patient has. 

PEARL 4

Dr. Aaron Dunn: Next up on common questions that come up surrounding pacemakers and ICDs! What type of anticoagulation is safe for patients undergoing a pacemaker or ICD procedure?

Dr. Andy Locke: If someone thinks that they need a pacemaker. What happens sometimes is a patient comes in on DOAC, but the team is like not sure if they need a pacer or a defibrillator, they stop the DOAC and start Heparin. That’s actually the opposite of what you should do. And a great pearl from this, a great pearl. What blood thinners are okay in interventional cardiology and what is okay in EP. And the answer is EP, never heparin. Never can use heparin. But actually there’s good literature showing that DOACs, you can do implants on DOACs and it’s safe. And its actually safer than to interrupt and then restart anticoagulation. There actually have been two really well done randomized trials.

Dr. Aaron Dunn: So those two really well done randomized controlled trials are BRUISE CONTROL and BRUISE CONTROL-2, which both studied patients on anticoagulation before pacemaker or ICD placement. In BRUISE CONTROL, patients were randomized to continue warfarin or bridge with heparin. And the study found that patients who were continued on warfarin had much lower risk of pocket hematoma. And for BRUISE CONTROL-2, patients were randomized to continue DOAC or hold DOAC without any bridging. And this study found that continuing DOAC wasn’t really better or worse than holding it. 

Dr. Shreya Trivedi: That really interesting! You know, I feel like knee jerk reflex in the hospital is to hold  someone’s DOAC or long lasting anticoagulation and switching to heparin drip for a faster on, fast off, peri-procedure. But it sounds like for EP-related procedures, like pacemaker or ICD placement, patients are actually better off if I avoid heparin products, so no bridging. And can just keep them on their home DOAC or warfarin.

Dr. Aaron Dunn: Yeah, I wonder why DOACs would be safer than heparin? Like you said, heparin is a faster on, fast off. That’s how I always think about it too. So I would have assumed it would be safer in this case? But it sounds like the evidence shows otherwise.

Dr. Andy Locke: For some reason, patients with this procedure, with vascular procedure in this area, there’s way more device related hematomas on Heparin or Heparin products versus anticoagulants. Like, like DOACs and Coumadin. I don’t really know why. So EP we’re okay with oral anticoagulation, we’re not okay with heparin because there’s there is so much bleeding in the pocket, that it’s almost guaranteed that you’ll develop a pocket hematoma. And any type of hematoma there is very high risk for infection, ongoing bleeding, needing to go back in and do a revision.

Dr. Aaron Dunn: And taking a deeper dive into the evidence, it looks like we should avoid heparin products for the days leading UP TO and at least 24 hours AFTER a pacemaker or ICD is placed to lower that risk of pocket hematoma. 

Dr. Shreya Trivedi: Yeah, the more you access a pocket, to say, evacuate a hematoma, the more the infection rate skyrockets, and particularly if it leads to persistent bacteremia, that will then mean device removal, which we learned in our last episode, is no easy procedure and carries a 1% serious complication rate.

Dr. Aaron Dunn: Ay yai yai!

Dr. Shreya Trivedi: Yes! Ay yai yai! Indeed! Aaron, do you want to summarize what we learned from this mini pearl?

Dr. Aaron Dunn: So to recap, it’s okay to either continue or hold oral anticoagulation for a patient with an upcoming pacemaker or ICD placement, but bottom line – we should definitely avoid heparin products in these patients. 

PEARL 5

Dr. Shreya Trivedi: Alright! Last, but not least! We’re going to end the episode looking into the future with Dr. Joshua Cooper, an electrophysiologist from Temple University, with a glimpse of newer implantable devices and how we might see something on ECG or x-ray that we might not have expected!

Dr. Joshua Cooper:  If you have somebody who has a conduction system pacing lead, you may see pacemaker spikes with a narrow QRS complex after that. That’s not something that most non-electrophysiologists are used to seeing. And so you may be confused and say, I don’t understand what’s happening in this patient because I see pacing spikes, but I see narrow QRS complexes and that’s not what I’m used to. I’m used to a wide Q, so left bundle branch block looking QRS. Why is that? Well, that’s a new technique that we’ve been using in the past few years that you may not be aware of. That can lead to very funny EKG appearances. You may see that a patient’s pacing and they may have no scar in their upper chest. And say, you may do a chest x-ray. There’s no pacemaker there. And you may not notice that there’s a small little metal bullet like device inside the ventricle that’s a leadless pacemaker that you may not have known was a device that exists. 

Dr. Aaron Dunn: Thinking back to our prior episode on pacemakers and ICDs, remember that leadless pacemakers are used for single chamber pacing, and because they do not have leads, they may be good options for patients with high infection risk or patients with poor vascular access options. So, people on dialysis. Also, one of the things we learned talking to Dr. Cooper is that some newer models of leadless pacemakers are being developed for the right atrium to promote AV synchrony, which would mean that more patients could benefit from these devices that have lower risk of infection.  

Dr. Joshua Cooper: So being aware that technology is constantly changing, if you see a scenario that you just can’t wrap your head around that you don’t understand what you’re seeing. Yet, another scenario to it is at a minimum, curbside the electrophysiology and say, I just don’t understand what’s happening in this patient. This EKG looks very funny to me. This x-ray looks very funny to me. What is that weird thing that I’m seeing in the body? In addition, and not to branch out in too far from our topic here, but there’s also a new type of pacemaker that is not intended to treat the heart rhythm, but in fact to increase contractility of the heart. It’s a called a CCM or a cardiac contractility modulation device. It has two leads that are implanted in the septum, in the right ventricle and attached to what looks essentially like a pacemaker. But this type of pacemaker is delivering very high frequency, high energy signals to those two leads in the septum on top of sensed QRS complexes. And over time, that can modify gene transcription and the contraction of the myocytes to take a heart failure patient who has a low ejection fraction and heart failure and improve their cardiac contraction. Not again, not a defibrillator, not a pacemaker, but looks like a pacemaker on an x-ray and will give you funny looking signals some of the time on an EKG. But it’s yet another new technology that we’re starting to use nowadays that someone may not even understand what that is. In fact, a lot of patients may have more than one device in place. They may have an ICD on one side of their chest and a CCM device on the other side of their chest doing two different things. And in the future, there’s going to be one device that will do all of the above, but that’s not currently the case. So keeping up with this technology is not your job, it’s our job. And certainly asking questions at any time is always acceptable and encouraged. 

Dr. Aaron Dunn: Wow, my jaw is on the floor! It just amazing to hear about these new technologies and how some devices are impacting contractility and treating heart failure. What are you taking away from this pearl, Shreya?

Dr. Shreya Trivedi: Yeah! I think for me the important take away is that when I am looking at an EKG, now with new pacemakers, like conduction system pacing devices, we’re not going to see some of those classic bundle branch patterns that we’re used to seeing.  

Dr. Aaron Dunn: Yeah, and I also think that when we’re looking at the chest x-ray that can also be a little tricky. For someone with a leadless pacemaker, we won’t even see the traditional generator and leads. And on the other hand, for someone with one of those cardiac contractility modulation devices, we might see something that looks like a traditional pacemaker but actually isn’t. Tricky, but exciting!

Dr. Shreya Trivedi: Yeah! I am really impressed by these new technologies that are coming out! But it also reminds me just to stay humble and remember that we’re going to continue learning and have some awesome cardiology colleagues to help us along. 

Dr. Shreya Trivedi: Alright! Let’s end with some quick pithy summary of our 5 mini pearls. Aaron, you want to take it away?

Dr. Aaron Dunn: Yeah! First, we talked about syncope. And one of my learning points is that prodromal symptoms, like nausea or diaphoresis, may not be as helpful as how someone feels AFTER a syncopal episode. They wake up and feel like something is off, think about vasovagal or orthostasis. If they wake up and feel totally normal, think cardiac syncope. 

Dr. Shreya Trivedi: Yep! And for our second and third mini pearls, we talked about surgery and MRI for patients with cardiac devices. So one lesson is that the cautery used in surgery or the MRI machine itself, can interfere with the normal function of these devices, so the device may need to be reprogrammed, especially in surgeries above the iliac crest. This could be as simple as leaving on a magnet to turn that pacemaker into an asynchronous pacing mode or getting cardiology to do some additional reprogramming with the ICD or those undergoing MRI. 

Dr. Aaron Dunn: Next, we talked about anticoagulation. And we learned that it’s really important to avoid heparin products in patients who are getting pacemaker or ICD procedures, because heparin can increase the risk of pocket hematoma! And it’s actually safe to continue their DOAC or warfarin.

Dr. Shreya Trivedi: And finally, we ended with a great reminder to continue reading up on new technologies that are coming out!

Dr. Shreya Trivedi: And that is wrap for this! If you found this episode helpful, please share with your team and colleagues. Give it a rating on Apple podcasts or whatever podcast app you use! It really does help people find us! Tweet or X at us and leave a comment on our website, or on instagram or facebook page. 

Dr. Aaron Dunn: Thank you to Dr. Shu Yang, Dr. Greg Katz, Dr. Abhi Gami, Dr Evan Harmon, Dr. Sarah Schwartz, and Dr. Aaron Troy for reviewing this episode. 

Dr. Shreya Trivedi: As always, we love hearing feedback. Email us at hello@coreimpodcast.com. Opinions expressed are our own and do not represent the opinions of any affiliated institutions. Take care!

References


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