Question on CHF exacerbation cause. Can post-op pacemaker cause this?

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Hello. I am a nursing student and I'm actually not sure if I'm asking this in the write forum. I need to complete a Care Plan and my patient had a CHF exacerbation about 3 days ago. She is 94 yrs old with hx of dilated cardiomyopathy and HTN, and her symptoms include dyspnea, orthopnea, fatigue.

I just wanted to know what could have possibly caused her exacerbation? I know she had a pacemaker placed about a week ago. I was trying to read the notes on her chart but it's a little unclear why this exacerbation started. Does it have to do with just "stress" from the surgery? Does it have anything to do with anesthesia?

I tried so much to look up the answer but there aren't any "nursing" answers and I'm really having trouble understanding why could have led to her exacerbation. Thank you.

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Specializes in RETIRED Cath Lab/Cardiology/Radiology.

Gosh, I have so many questions.  There are some very sharp members who will hopefully weigh in on this with their input.

Is the pacemaker a single-chamber or double-chamber?  

What is her cardiac rhythm (is she in atrial fibrillation)?

Do you know why the pacemaker was implanted?  (e.g., sick sinus syndrome, symptomatic bradycardia, etc)

Were any of her routine medications discontinued after the pacemaker was implanted?

Just as a matter of information, if the patient is cooperative, a pacemaker is usually implanted under moderate sedation only, NOT general anesthesia.   This may change if the patient is severely claustrophobic or suffers from severe PTSD or is unable to cooperate with lying still for the procedure.

It would be interesting to ask the patient's physician for his/her input on why this situation developed.  I would want to review the most recent pre-pacemaker implant echocardiogram; I assume this exam is the one (plus review of symptoms) with which her Cardiologist is monitoring the cardiomyopathy.  It is possible the presence of the pacemaker lead would cause significant valvular insufficiency, enough to develop the patient's symptoms.   This might be detectable via auscultation or it may show up on a post-pacemaker echocardiogram.

Some things to look up with a web search (since you asked specifically):

1. chf after pacemaker implant (some articles I skimmed for this, it seems if chf develops or exacerbates, it will be within six months of pacemaker placement, not within one week)

2. pacemaker lead valvular insufficiency (here's one article: https://heartcare.sydney/right-heart-failure-pacemaker-induced-severe-tricuspid-regurgitation/)

The short answer is yes, it is possible, especially if she was very borderline before.  As for her CHF and post-pacemaker nursing goals:  Frequent monitoring of vital signs, including oxygen saturation, heart rate and rhythm; Continue with her meds as ordered; observe for edema, increasing fatigue, and shortness of breath; auscultate for lung sounds; monitor labs for deviations (especially with Na+ and K+, and observing BUN and creatinine for renal status); continue with low-sodium diet; monitor daily weight and report weight gain of 3+ lb overnight or a continued rise in weight as opposed to steady weight. 

Is she ambulatory or bedridden?  If she is bedridden, turn every two hours, and closely observe dependent areas for signs of edema and/or breakdown.

Best to you, hope she improves.

 

 

 

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dianah said:

Gosh, I have so many questions.  There are some very sharp members who will hopefully weigh in on this with their input.

Is the pacemaker a single-chamber or double-chamber?  

What is her cardiac rhythm (is she in atrial fibrillation)?

Do you know why the pacemaker was implanted?  (e.g., sick sinus syndrome, symptomatic bradycardia, etc)

Were any of her routine medications discontinued after the pacemaker was implanted?

 

Wow thank you for all this information! I appreciate all this help.

Unfortunately I don't know if her pacemaker is single or double chamber. Her echocardiogram revealed: ejection fraction is 20-25%, mild to moderate mitral valve regurgitation.

She also has a hx paroxysmal atrial fib. Her ECG revealed atrial-speed ventricular-paced rhythm, buventeicular paced rhythm. —> I actually don't even really know what this means... so I'm not sure if this info answers your questions.

She also has heart murmurs "grade 3/6 pan systolic, high frequency murmur.” I don't know what this means either. Sorry!

Still, I'm really thankful for your response and your help. Thank you for your info on interventions! Have a great night!

 

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Specializes in RETIRED Cath Lab/Cardiology/Radiology.

Thank you. 

Given her EF of 20-25%, and the ECG report (which is probably "atrial-sensed, ventricular-paced, bi-ventricular paced rhythm"), she has a bi-ventricular pacemaker, implanted for cardiac resynchronization therapy.  There is a lead in the right atrium (doing the sensing, in her case -- which fact reveals she is in an underlying sinus rhythm.  If she were in atrial fibrillation, there would not be a regular P wave for the lead to sense).  There is a lead in the right ventricle, which stimulates the right ventricle (coordinating with the atrial sensing the patient's own P wave), and another lead placed in the coronary sinus, which stimulates the left ventricle.  The point of cardiac resynchronization therapy (crt) for heart failure patients, is to increase the efficiency of the heart's pump by stimulating the ventricles in a coordinated fashion -- coordinated to the atria and coordinated with each other.  Most patients report decreased fatigue and increased energy after implant of the biventricular pacemaker for crt.

A pacemaker lead is more likely to cause tricuspid insufficiency, just by its presence going through the tricuspid valve.  The patient's mitral insufficiency will not be affected by the pacemaker leads.

It's hard to tell what changed with her, to bring on the CHF exacerbation.  Would need more info. ?  Again, would like to hear what her MD or NP have to say about this.  At this point, it's probably moot: just treat the exacerbation and keep an eye out for possible future triggers.

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dianah said:

Thank you. 

Given her EF of 20-25%, and the ECG report (which is probably "atrial-sensed, ventricular-paced, bi-ventricular paced rhythm"), she has a bi-ventricular pacemaker, implanted for cardiac resynchronization therapy.  There is a lead in the right atrium (doing the sensing, in her case -- which fact reveals she is in an underlying sinus rhythm.  If she were in atrial fibrillation, there would not be a regular P wave for the lead to sense).  There is a lead in the right ventricle, which stimulates the right ventricle (coordinating with the atrial sensing the patient's own P wave), and another lead placed in the coronary sinus, which stimulates the left ventricle.  The point of cardiac resynchronization therapy (crt) for heart failure patients, is to increase the efficiency of the heart's pump by stimulating the ventricles in a coordinated fashion -- coordinated to the atria and coordinated with each other.  Most patients report decreased fatigue and increased energy after implant of the biventricular pacemaker for crt.

OMG!! Thank you! You are so incredibly helpful. You gave me so much info. Thank you again!

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