AICD, Vfib, a low battery, and a lot of questions

[richkundrn]

I'm a NICU RN, which leaves me rather clueless when it comes to my 60 yr old father and his heart condition, so I am seeking some help here. While at the lake fishing Monday night, my father collapsed. He was unconscious for 5 to 6 minutes and when his AICD was read later it showed that he had abruptly gone into Vfib and the AICD took 22 seconds to charge and then defibrillate. He had the AICD implanted 5 or 6 years ago. He's been defibrillated three times since he's had it. The first time was 2 or 3 years ago. He was loading roofing material into a truck in the afternoon (leave it to my dad... ). The second time was this last November. He was at home, sitting in front of the computer.. that time the AICD showed he first went into Afib which triggered Vfib(?). His previous history includes going into cardiac arrest at age 43 or 44 and a few months later having a triple CABG. With this last incident, after being taken to a hospital that could not serve him, and going through an insurance nightmare, what was finally discovered is that he needs to have his AICD battery (or unit?) replaced. The docs believe his leads are in good condition and probably won't need replacement. The cardiologist felt it was urgent enough to go ahead and operate tomorrow, until he was reminded that my dad is on 10mg Coumadin q day. Also, from the most recent reading his AICD is pacing about 90% of the time, due to atrial Fib. I believe his AICD is a dual lead. I'm about 900 miles away from my dad right now and I'm getting all this information from family members who seem to get things rather confused. I have questions about this surgery. Will he be under general? How invasive is the procedure? While the AICD is disconnected do they use external pacing? What are the greatest risks? How soon after going into Vfib will they generally perform this procedure? If for some reason they have to replace leads, what are the risks? Also, with this last episode, his HR was around 100 before he went into Vfib. He was walking back and forth about 50 yards from the lake's edge to his car, loading fishing supplies (although nothing really heavy) into his car. I'm just concerned that his "threshold" for going into Vfib is much lower than it was even a year ago. Last year during hunting season he managed to drag a deer who knows how far (ofcourse, at his next AICD reading he was in trouble with his nurse who asked "What on earth were you doing this time?" :) ) Who knows what rhythm he was in... but it was nothing bad enough to require a shock. My dad is a stubborn old man who says himself that he knows he's living on borrowed time. Even if anyone in the family wanted to try and limit his activities, it would be fruitless. After talking with my sister (who was with him at the lake) we both agreed that if the worst had happened that night, it couldn't have happened in a better place. Afterall, the next night he bragged to me about the big fish he had hooked!!

[suzanne4, RN]

Yes, he will definitely have an external pacer on before his chest is even prepped. If his AICD is pacing, then again, yes it is a dual lead. Whether or not he needs to have the leads replaced won't be known until he gets to the OR. We try to avoid changing them if we don't need to. There is no time limit to wait for changing an AICD or putting one in due to vfib. Remember that was the reason that is was placed to begin with. Once the wires are placed and checked, we do testing for the settings, and then also put the patient into vfib to make sure that the defib will work and at the proper threshold. So, they will be checking all of the parameters again while they are doing the procedure, and then again in the PACU.

Anesthesia completely depends on his surgeon and anesthesia team. Remember that they will be defibrillating him to test everything.

Chances are that they will be changing out his pack, newer versions keep coming out and they may have something that will work better for him, especially since it is already about 5 years old.

When you see him, just give him a big hug! :balloons:

Hope that this helps you....................

If you need any more specific info please feel free to PM me. Before moving entirely to Bangkok last year, I was a member of a heart team at several different hospitals.

[Dinith88]

If he only needs a battery change, then the procedure will be be quick and 'simple', with either local or MAC, there's no need for general with a battery or device change. The lead placement is the hard part and since he's already got functioning leads, they'll only have to open his 'pocket' (just under the skin) and pop in a new battery. If they opt for a new system, it'll still be relatively 'easy' to do, as his leads are in place and mature. He wont have all the arm restrictions he had with his first implantation. Even if he gets a new lead, it'd be unlikely that he'll be given general anesthesia, as these procedures are routinely done in EP-lab under flouro. AICD lead placement done in surgery is the exception,-not the norm- and is reserved for patients who are unable to have their leads/devices placed successfully in the EP-lab.

Some times (especially with the earlier devices), a-fib can trigger shocks...in people with co-existing bundle branch blocks(your dad has a pretty significant cardiac history and may indeed have a bbb). If the a-fib gets fast enough, and the patient has a bundle branch block, the rhythm can 'look' like v-tach (fast, with wide complexes) and may trigger a shock. Theses machines can be fine-tuned to identify and ignore a-fib w/bbb...but it's tricky. BTW, this probably is NOT the case with your dad as he collapsed. A-fib would have to be going on for awhile before he went out...he'd of felt it coming. I've been with patients who were being shocked by their AICD, and the shock happens within a few seconds. 22 seconds is too long...and the docs are probably right in that he just needs a new battery. Bad leads wouldn't cause the aicd to have a prolonged charge-time.

(BTW, the previous poster mentioned that they wont know about lead function/replacement until 'surgery' and thats not exactly true. They can test thresholds and lead function with non-invasive techniques at the bedside (more likely in an ep-lab)...but they can ALSO tell how well they function by interrogating your dads device (which is what they did when they 'saw' what happened during his episodes) ...your dad probably wont even go into an OR...this can all be done in the lab. Again, surgical(under general anesthesia) placement of leads/aicd/pacer's is NOT routine)

[richkundrn]

Thanks for the replies! I really appreciate it. It's difficult being so far away and trying to rely on information from family, etc.

Dinith-- this last shock he recieved a few nights ago, he was in vfib and it took 22 seconds for the AICD to charge and shock him. It's just so scary to think that this device that has saved his life numerous times might have failed this time around all due to a low battery! Anyhow, hopefully I can get a chance to speak with one of the myriad of people managing his care and get a bit more info. (He's recieving care at a huge teaching facility.. one of those places with the reputation of "kill em or cure em".)

If anyone knows of some good online resources where I can get more information that would be great!

Thanks!

[IamRN]

if anyone knows of some good online resources where i can get more information that would be great!

thanks!

online information, sources, and support is awesome! however, it doesn't replace hearing it from the horse's mouth. i would strongly urge you to consider speaking directly to your father's physicians (w/your dad's ok of course!). i am sure they will be able to answer your questions 100%!

i work in an sicu (we do open hearts and other cardiothoracic treatments). the surgeons and others involved in the case often speak to family who cannot be there (again, w/pt's ok) for further questions and clarifications.