V-tach with minor surgery

[Pamz]

My son had surgery on Monday to put pins in his wrist because he broke it.  This was done at an outpatient surgery center, which, I didn't agree with because of his sudden cardiac death history, but, I was 2000 miles away and wasn't told about it until the day of the surgery and he is 24 years old.  Anyway, they had to shut his pacemaker/defibrillator off and sure enough, even though he was awake during the surgery, they had to hit him with the paddles because his heart rate became erratic. They called today to explain what had happened and said his heart rate was not high, only around 80 but he was in v-tach.  

Question - 1 - he was wondering if his defibrillator would go off at 80 with v-tach since it is set for a high of 180, and 2 - what actually is v-tach and how bad is it?

[Pamz]

My son's icd, which does have the pacer also, has fired on him a couple of times.  You can hear it winding up but he says so far the jolt has been insignificant.  However, his cardio told us that the shock given is based upon the heart itself.  If you are suffering heart failure or your heart is damaged, the shock is going to be much more than one like my son, whose heart is healthy.  We were so worried his was gonna go off during his wedding ceremony back in May because he could feel his heart beating out of sync but, he kept it calm enough to make it through it.

Ptadvoc8:  Mayo is excellent and thorough - was there last year with my husband for a whole slew of things that starts with a back injury to complications of all the steroid shots as well as sleep apnea.  Very good but also very intense and busy.  They kept us a whole week but I believe we'll only be a couple of days with my son.

[ptadvoc8]

Pamz - Not sure this is the answer you are looking for, but it is my understanding is that you can have short runs of non-sustained ventricular tachycardia (NSVT) for, say, 8-10 beats that occurs once, or off and on for several minutes, in which during those short bursts of time, the heart will beat very fast, but as these are interspersed between NSR beats, the overall heart rate for any measured incremental time interval could be less than the 180bpm (or whatever) that the target rate is set for on the ICD. So, there may have been V-Tach and they picked it up on the monitor, but if it was not sustained, the overall HR for the time interval duration may only have been 80bpm. In some ICDs there is a "pacing function" that will try to "pace" the rhythm out of V-Tach (or whatever the abnormal rhythm is) in an attempt to get the heart back to NSR. Depending on how it is set, this function may go off (and is sometimes felt by patients) and "reset" the heart to NSR before the heart reaches that 180 high bpm rate that actually triggers the ICD to deliver it's jolt. BTW, I am going to Mayo in September for evaluation and so far (without having even arrived yet) I am very impressed with their services. I have been dealing with my arrhythmia and various medical professionals for over 40 years and so far Mayo strikes me as very thorough and professional -- at least in the way they have handled my case prior to the actual appointment. Best wishes and good luck in October!

Lisa - I have a couple of good friends who have ICDs, one due to idiopathic cardiomyopathy with a confirmed history of V-fib and one who experienced SCD for unknown reasons but had the ICD implanted just to be safe. One has been "defibbed" once and she said it was definitely like getting "kicked by a mule" and while it was disconcerting to her, she also found it reassuring to know her "defibber" was working as it ought to. The other has been "defibbed" several times and swears he hardly notices it! The first has an ICD with pacing capability and the other a straight ICD with no pacing capabilities and I have no idea whether that makes any difference in the number of shocks each has had, or in the strength of the shocks delivered, or in their reaction to the shocks themselves. I'm just glad to hear that you are feeling so much better now!

[Mom2four85]

Ouch glad to know about some of these things.  I'm aborbing everything I can about pacer/icd's and how they work at this point.

I just got a Teligen 2 lead pacer/ICD implanted and was wondering some of these things.  Of course they tell you the whole spiel in the hospital then the handy dandy book; but things don't always go as planned and aren't exactly what they tell you.

I have noticed a few times since Friday that my heart starts to race and then I get some twinges or pains and I assume the pacer is doing its job pacing so I don't get a jolt from the icd.  

They told me it would be 15-25 sec if the icd picks up a rhythm - giving your body time to respond and recover first.  Ill have to ask next Wed what mine's set at to fire just so I know.

When the icd fires does it jolt like kick you like they say ? I read some jolts can actually knock you off your feet?

[Pamz]

Well, I hope this is an insight to what can trigger his bad rhythms and point to the actual defective gene.  We'll definitely be taking all his records up to the Mayo.

His Dr said that his icd will notice a bad rhythm and will prepare to fire and actually will fire if it continues, no matter what the bpm is.  And, I guess we've actually seen that once before, where his bpm was less than the 180 that it was set for, it fired at 150.  He was jogging and watching his polar monitor and when he hit 170, he stopped jogging and his bpm dropped to 150 but, his icd fired anyway.  

[Wisconsin2007]

You're probably right about the v-fib for your son causing his SCD, because other than his heart simply stopping, nothing else (someone correct me if I'm wrong) can cause SCD.  V-fib is the heart rhythm boogeyman.  

I wish I knew more about how the pacers/ICDs work, but I know they have amazing capabilities.  And who knows - your son's might have untapped abilities that just need a little programming or setting adjustments, now that the doctors (hopefully) know a bit more about what's causing his rhythm issues.

[PikaPika88]

I'm not a knowledgable patient.  Correct me if I'm wrong.  I have a 2 leads pacemaker.  No ICD component.  My cardio told me when it senses abnormal rhythm, it'll pace it out.  I still get pace when my rate at 70.  For me it sounds pretty normal but it paced. May be it is the abnormal rhythm.  Pacemaker won't wait for 25 seconds or missed 25 beats then start action.  May be it was the ICD will delivery "shock" timing.  When my pacemaker picked up 2 beats late, 2 nurses ran beside my bed and woke me up.  I don't know that 2 beats were what kind of rhythm?  

I got various of rhythms.  Diagnosed with wpw, SSS, AF and stress test it showed Brugada variant.  I had my av node ablated so now I'm relying on the accessory pathway to do the conduction.  

[Pamz]

Yes, he's been tested for brugada and many other things.  We still don't know what caused the scd to begin with and we're taking him to Mayo in October for more tests.  I questioned the v-tach at 80 as I always thought any tachycardia wa over 100 but they said it was erratic also, so it probably was like itdood said, not ful v-tach.  We will call his cardiologist on Monday and ask when it would fire.  My son always thought it was just when his bpm got too high and I thought it was whenever it noticed a bad rythm and now I'm curious as to how long that rythm needs to be bad, whether it's 25seconds or not.  

Thanks for the info on v-tach.  Actually, I think they thought he had gone into v-fib last year when he suffered scd but, what came first, still no clue.

[itdood]

It makes sense that they would turn off the ICD with anesthesia, no matter where it was done.  The anesthesiologist and EKG equipment are now doing a better job of monitoring him than the ICD, and should he need to be shocked out of v-fib there could be much conflict if the ICD is firing and the docs are trying to guess when and deliver care.  If they were to rely on the ICD, they would literally have to stand back and hope it does the job, I can't see docs doing that.

What I'm thinking happened is that they knew his history and were being extra careful with his rhythm.  He probably wasn't in true v-fib but they may have felt he was heading there and preempted.  The bpm of 80 is not v-tach, and usually the ICD is set to go off after 25 seconds of vfib (I thought).  Might want to call them back and get more info.

[Wisconsin2007]

I'm curious as to why they needed to shut off his pacer.  I'll admit I don't know that much about ICDs, but I would think the wrist would be far enough away from the ICD that any electrically-powered equipment wouldn't pose a hazard.

Could his unit detect a low rate V-tach, I couldn't say.  You'd have to ask his doctor.  Actually, wait a sec.  For it to be v-tach I thought it needed to be more than 100 bpm.  At a low rate like that it sounds more like AV block.

As for whether v-tach is bad - well, it's not good, I'll say that much.  V-tach is when the ventricles are contracting independent of the signal coming from the AV node (which came from the atria).  So the top of the heart and the bottom of the heart are no longer working in concert during v-tach.  The fear is that v-tach can lead to v-fib, which is the most dangerous type of arrhythmia one can have.  

Your son was tested for Brugada, right?  That's a polymorphic ventricular tachycardia that can lead to ventricular fibrillation, which without medical intervention results in SCD. Again. Now as I understand it, no signs of Brugada came out in his test, right?  That's good.  As I understand it, the meds they gave him were designed to bring about detectable ECG changes that would allow for a Brugada diagnosis.

I'm in a little over my head with this discussion, but I wanted to at least give you some info to grab hold of.