Dispositivos implantables: Desfibriladores y resincronizadores


Los Desfibriladores implantables (DAI) y los Resincronizadores Cardíacos (CRT) en sus dos modelos disponibles: Resincronizador – Marcapaso (CRT-P) y Resincronizador-Desfibrilador (CRT-D) forman parte del arsenal terapéutico de los pacientes con Insuficiencia Cardíaca (IC).

¿Qué es un DAI y un resincronidazor?
Un Desfibrilador Automático Implantable (DAI) es un dispositivo parecido a un marcapasos que controla continuamente el ritmo cardiaco. Si detecta un problema del ritmo que no es demasiado grave, libera una serie de impulsos eléctricos indoloros para corregir el ritmo cardíaco.
Un TRC-D es un desfibrilador implantable con terapia de resincronización cardiaca (TRC) en los pacientes con insuficiencia cardíaca. El dispositivo monitoriza el ritmo del corazón, detecta irregularidades y las corrige con impulsos eléctricos.
¿Para qué sirve un DAI?
Los DAI se utilizan en personas con riesgo de alteraciones graves del ritmo cardiaco del corazón que es  la causa principal de la muerte súbita. En los pacientes con riesgo de arritmias ventriculares estos dispositivos prolongan la supervivencia. Es frecuente que se combinen un DAI con un TRC en el mismo dispositivo. En este caso, el dispositivo se denomina TRC-D (dispositivo de resincronización asociado a un desfibrilador).
¿Cuál es la base del funcionamiento del DAI y/o TRC

  1. Detectar las señales cardiacas apropiadas.
  2. Diagnosticar las arritmias.
  3. Proporcionar las terapias antitaquicardia programadas (los TRC pueden tener esta función TRCD o carecer de ella TRCP).
  4. Función MARCAPASOS.
  5. Suministrar información complementaria sobre la estabilidad funcional cardiaca del paciente y sobre el funcionamiento del dispositivo.

¿Cuál es el protocolo de seguimiento de DAI Y CRT (P/D)?
El seguimiento de pacientes portadores de DAI y CRT (P/D) lo podemos sistematizar en cuatro objetivos básicos: la valoración clínica del paciente, evaluación del funcionamiento del dispositivo, ajuste en la programación del dispositivo e instrucción y asesoramiento del paciente.
Una de las complicaciones más importantes es la infección de la bolsa (zona donde se encuentra alojado el generador) que puede llegar a ser grave y requerir la explantación de todo el dispositivo. Estas infecciones pueden aparecer de forma temprana o años después de haber sido implantado el dispositivo. Es muy importante realizar un diagnóstico temprano por lo que recomendaremos una vigilancia diaria de la zona.
Sospecha de infección: piel con signos in amatorios (calor, enrojecimiento, dolor), cambios tróficos en la piel (piel adelgazada, depilada, adherida al dispositivo), aparición de granulomas y/o exudado, apertura de la piel con visualización de partes del dispositivo…
Muchas veces, en el postimplante inmediato aparecen hematomas leves que no suelen dar problemas. Por el contrario los hematomas a tensión e indurados requieren una vigilancia diaria por tener más riesgo de infectarse. Los hematomas que evolucionan bien se resuelven en el plazo de 3-6 semanas.
Ante una bolsa patológica está contraindicado la punción diagnóstica o evacuadora por el alto riesgo de contaminación bacteriana da la misma.
¿Qué medidas  se deben aplicar en el postimplante precoz?

  • Cuidados higiénicos de la herida quirúrgica.
  • Vigilar la aparición de fiebre.
  • Vigilar la aparición de hematoma o signos in amatorios en la bolsa del generador.
  • Retirar grapas a los 8 días del implante.
  • Movilización progresiva del hombro y brazo del lado del implante.
  • Evitar ejercicios físicos intensos y/o cargar pesos moderados con el brazo del lado del implante.
  • ACUDIR A LA CONSULTA DE SEGUIMIENTO EN CASO DE DETECTAR CUALQUIER ANOMALÍA EN SU EVOLUCIÓN

¿ Qué medidas  se deben aplicar en portadores de dispositivos?

  • Vigilancia de la zona de la bolsa: contactar con la unidad de seguimiento en caso de notar cambios o dolor.
  • Actividad física: Evitar cargar pesos importantes en la zona del generador y los golpes directos sobre el sistema.
  • Actividad laboral: informar a los equipos de salud laboral de su empresa de que es portador de un dispositivo.
  • Actividad doméstica:
  • Cocina de inducción: mantener una distancia de 60 cm cuando esté funcionando.
  • Usar con precaución aparatos que generen vibraciones (taladros, cortacésped..)
  • No usar aparatos de soldadura
  • Consultar antes de adquirir sistemas con ondas electromagnéticas (colchones…)
  • Pruebas médicas: Siempre que acuda a una consulta médica, debe llevar la tarjeta de portador de DAI o CRT e informar siempre al médico prescriptor y al Servicio de Radiología que realiza la RM que es portador de un dispositivo.
  • En caso de Intervención quirúrgica, sesiones de Radioterapia, sesiones de litotricia, cardioversiones, o pruebas médicas de Neurofisiología, endoscopia digestiva o aplicación de terapias eléctricas para el dolor, debe informar al equipo correspondiente.

 Nerea García Granja
Enfermera residente, EFyC, C. S. La Victoria, Valladolid

REFERENCIAS:

  1. Martinez Ferrer J. coordinador. Monitorización domiciliaria en Estimulación Cardíaca. Madrid: SEC; 2016.
  2. Moro Serrano C, Hernández Madrid A. Estimulación cardíaca, desfibrilación y resincronización. Madrid: Mc Graw-Hill; 2006.
  3. Quesada Dorador A. editor. Dispositivos implantables en Insu ciencia Cardíaca. Madrid: TCC; 2008
  4. Mont L, Hernandez Madrid A. Resincronización cardíaca. Barcelona: ICG Marge; 2006.
  5. López Arroyo F, Reyes Armilla A. Des briladores cardioversores automáticos implantables. Enf Car(Val).2002;39-42.
  6. Peinado Peinado R, Merino Llorens JL, Hernán Roa Rad J, Macía Palafox E, Quintero Henson O. Calidad de vida y estado psicológico de los pacientes portadores de des brilador automático implantable. Rev Esp Cardiol. 2008;8(Supl A):40-50.
  7. García-Morán E, Bustamante-Munguira J. Terapia de resincronización cardíaca en Insu ciencia cardíaca. Cir Cardiov. 2011; Vol (18):133-43.

Revisado: marzo 2018

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