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Our Process - Treatment - Device Therapy

Device Therapy

Pacemakers are implanted to treat slow heart rhythms and heart block. These devices may also be used to allow medical therapy which may otherwise slow the heart rhythm. Defibrillators are implanted for treatment of fast life threatening rhythms originating in the lower chambers. They are also used for prevention of sudden cardiac death in patients at high risk of developing these fast, life threatening rhythm (those with weak heart muscle).

Bi-ventricular pacing is used in patients with weak heart muscle along with abnormal electrical signaling in the lower pumping chamber. They work by resynchronizing the contraction of different walls of the heart muscle thereby making the lower pumping chamber more efficient.
 

Pacemaker
Implantation		 Defibrillator
Implantation / ICD		 Cardiac
Resynchronization

Pacemaker Implantation

A pacemaker is a small electronic device that helps the heart to beat at a proper rate. It keeps track of your normal heart beat, and can sense when it becomes too slow. When that happens, the pacemaker generates a small electrical impulse, very similar to the heart's natural impulse. This keeps your heart beating at a normal pace.

Your pacemaker has two main parts: the generator and the lead(s). The generator is a small, flat, lightweight metal case that contains a tiny computer and battery. This is the part that generates the electrical impulses. The leads are wires covered by soft, flexible plastic. Working together to regulate your heart, they monitor how well the heart is beating and will send electrical impulses from the generator to the heart when it senses it is necessary.

Preparation
Prior to your procedure, we may request tests, such as an electrocardiogram (ECG) and blood tests. We will review all medications you are taking, and give you any special instructions concerning them. You'll be told where and when to report for your pacemaker (unless you're in the hospital) and what to do before you arrive. Generally, you'll be asked not to eat or drink anything after midnight the evening before your procedure (except sips of water to swallow your pills).

Just before your procedure, we will discuss your pacemaker insertion - its purpose, benefits, and potential risks. The insertion of a pacemaker is a common, low-risk surgical procedure with a very small risk of complications. These might include puncture of the heart or lung tissue, damage to the vein, infection, bleeding, and/or bruising. Although the rate of complications is very low, you'll be asked to sign a routine consent form. This is a good time to ask questions or talk about any concerns you may have.

Procedure
Before your procedure, an intravenous line (IV) will be inserted in your arm to administer any medications. The area where the pacemaker will be inserted will be washed with an antiseptic soap and shaved. You will be taken to a special procedure room where you'll be covered with sterile drapes. You'll be awake through the procedure, but will be given a sedative to help you relax and make you drowsy.

The procedure room personnel, who have been trained specifically in the electrical activity of the heart, will be wearing surgical hats and masks to assure that the environment is kept as clean as possible. Your ECG, heart rate, blood pressure, and oxygen level will monitored throughout the procedure.

A local anesthetic will be injected under the skin to numb the site where the pacemaker will be implanted in the upper part of the chest. Then the electrophysiologist will make a small incision, and form a "pocket" under the skin to hold the generator. The leads will be inserted into a vein under the collarbone and guided into your heart using an x-ray monitor, and tested periodically to determine their best positioning. After the leads are in place, they will be attached to the generator, which will then be gently placed into the skin "pocket". Then the incision will be closed with dissolvable stitches and a small bandage applied.

During the procedure you may feel some pushing and tugging on your skin. However, you should feel very little, if any, discomfort overall. The procedure usually lasts approximately one hour.

Recovery
After the procedure, you'll be taken to a hospital room or a recovery area. You'll be kept overnight in the hospital so your heart can be monitored to make sure your pacemaker is functioning well. You'll be asked to limit the use of your arm on the side the pacemaker was inserted to give the leads an opportunity to heal to your heart tissue.

You may feel some discomfort in the incision area when the local anesthetic wears off. If so, the staff will give you some medication to make you more comfortable. Be sure to tell your nurse if you experience any unusual symptoms such as hiccups, dizziness, or chest pain. Before you leave the hospital, you'll be given detailed instructions about caring for your incision site. You'll also be told what signs and symptoms to report, and you'll be given a follow-up plan. You should arrange ahead of time for someone to drive you home.

Follow-up care
Your pacemaker will help make sure your heartbeat remains strong and regular, but you also play an important role in staying healthy. Be sure you understand your follow-up plan and keep all appointments for exams and follow-up tests. Follow your instructions, don't hesitate to talk about your concerns, and immediately report any new symptoms.

As always, if you have any questions, be sure to call our office.

Defibrillator Implantation

Background information
Ordinarily, your heart beats at a regular, steady pace called normal sinus rhythm. It is regulated electrically by the sinus node. However, if certain cells in the lower chamber of your heart (the ventricles) begin to generate their own electrical impulses, these can override the heart's normal electrical control mechanism. These impulses do not follow the heart's normal conduction pathway, and may prevent the heart from pumping enough blood and oxygen through the body. One situation, called ventricular tachycardia (VT), may cause you to feel fluttering in the chest or throat or a sensation of dizziness and lightheadedness.

Because less blood is pumped with each beat, your body and brain receive less oxygen-carrying blood, which may result in dizziness, blackouts or fainting, and even unconsciousness. Sometimes VT can be prevented or treated with medications. In other cases, an electrical device is needed to deliver an impulse to the heart to stop the arrhythmia.

When the ventricular arrhythmia becomes even more rapid and unstable, it causes a condition called ventricular fibrillation (VF)-the heart is quivering, and no longer pumps any blood. This leads to cardiac arrest. The only way to correct ventricular fibrillation is to quickly deliver a strong electrical shock to the heart to stop the abnormal rhythm and prompt the heart's normal electrical conduction system to take over again. This process is called defibrillation.

Your Implantable Cardioverter-Defibrillator
In a hospital or ambulance, when emergencies cause life-threatening arrhythmia, defibrillation is done with an external device called a defibrillator. Paddles are placed against the chest, and a strong electrical impulse is delivered through the heart. However, if your arrhythmia (either ventricular tachycardia or fibrillation) occurs in routine situations, an automatic implantable cardioverter-defibrillator (ICD) can be implanted to monitor and deliver whatever therapy is necessary. It will be programmed to detect and diagnose either ventricular tachycardia or ventricular fibrillation, and will deliver the therapy necessary to correct your abnormal heart rhythms.

Your electrophysiologist may choose to implant a defibrillator in your body to monitor your heart rhythm around the clock and to immediately correct any dangerous arrhythmias if they occur.

The ICD has two components: the generator and the lead(s). The generator is a relatively small, flat, lightweight case that holds a tiny computer and battery. This will generate the electrical impulses used to regulate your heartbeat. The leads are wires covered with soft, flexible plastic. They are connected to the generator and "tell" it how the heart is beating. The leads also transmit the electrical impulses from the generator to the heart.

Preparation
We will discuss the procedure-its purpose, benefits, and potential risks - before you receive your ICD. Inserting an ICD is a common, low-risk surgical procedure with a very small risk of complications. These may include: puncture of the heart or lung tissue, damage to the vein, infection, bleeding and/or bruising, or other uncommon events. You'll be asked to sign a surgical consent form before you have this procedure. If you have any questions or concerns, be sure to call our office.

We will also order a series of tests prior to your ICD. These will include an electrocardiogram (ECG) and some blood tests. We will also go over all medications you're currently taking and give you any special instructions concerning them.

Procedure
Usually you'll be instructed not to eat or drink anything after midnight the evening before your procedure. You may, however, take sips of water to swallow pills. If you're coming to the hospital as an outpatient, you'll be told where and when to report. You should plan for an overnight stay and arrange for someone to drive you home.

Just prior to the procedure, an intravenous line (IV) will be inserted into your arm to administer any necessary medication. You will be moved by stretcher to an electrophysiology (EP) laboratory where you'll be positioned on a special table and covered with sterile drapes. An anesthesiologist will be present to administer medications as needed to keep you comfortable. The area where the ICD will be inserted will be washed with an antiseptic and shaved, if necessary. The entire EP staff, who has been trained specifically in the electrical activity of your heart, will be wearing surgical hats and masks to assure that everything remains sterile throughout your procedure.

As the procedure begins, you'll receive an injection to numb the ICD insertion site. A small incision will be made, and a small "pocket" formed under the skin in your upper chest. Then a lead will be threaded into the vein that runs just below the collarbone. This lead will be guided into your heart using a x-ray monitor.

Once in place, it will be tested to make sure it's in the best possible position. Then, it will be attached to the ICD generator, which will be placed in the pocket under your skin. At this point, you'll be given some additional medication by the anesthesiologist through the IV that will put you deeper to sleep for a few minutes. While you're asleep, the ICD will be tested to be certain it is functioning properly.

When your EP team is certain your ICD is securely in position and will do its job well, your incision will be sutured (stitched) and covered with a small bandage. Throughout the entire procedure, which takes about 1 1/2 to 2 hours, your ECG, heart rate, blood pressure, and oxygen level will be constantly observed on monitors in the laboratory.

Although you may feel some pushing and tugging on your skin at times, there should be little or no discomfort during the procedure. If you feel any discomfort, tell the physician or staff immediately.

Recovery
After your procedure, you'll be taken to a hospital room or recovery area. You will be kept overnight in the hospital so that your heart can be monitored to be certain the ICD continues to function properly. You'll be asked to limit the use of your arm on the side the ICD was inserted. A sling will be placed over your arm overnight. This gives the lead a chance to begin "healing" into your heart.

If you begin to feel some discomfort in the incision area when the local anesthetic wears off, let the staff know and they'll give you some medication to help make you more comfortable. Be sure to tell your nurse if you experience any unusual symptoms such as hiccups, dizziness, or chest pain.

Make sure you arrange for someone to drive you home when you are discharged. Before you leave the hospital, you'll be given detailed instructions about caring for the incision site. We will also explain follow-up plans, and discuss what signs and symptoms should be reported.

Follow-up care
Your ICD will help protect you against dangerous heart rhythms. However, you also play an important role in staying healthy. Be sure to keep all appointments for exams and follow-up tests. Follow your instructions, don't hesitate to talk about your concerns.

As always, if you have any questions, be sure to call our office.

Cardiac Resynchronization

Heart failure is a common and serious medical condition. Heart failure develops slowly over time as your heart muscle gradually weakens. The "failure" refers to your heart's inability to pump enough blood to meet your body's needs. Congestive heart failure is a progressive condition in which the heart's function gradually deteriorates resulting in diminished cardiac performance and pumping ability. Ultimately, blood flow to the organs is reduced, leading to a variety of symptoms including shortness of breath, lack of energy, swelling, etc. Patients with heart failure often require repeated hospitalizations for treatment and adjustment of medications. Medications have been the mainstay of therapy for heart failure. However, patients with extreme forms of heart failure often remain highly symptomatic despite maximum medical therapy and these patients may benefit from cardiac resynchronization.

Anywhere between one quarter to one half of all heart failure patients have delay in the electrical activation of the heart making the heart walls dys-synchronous and heart pump less efficiently. This electrical abnormality is often associated with electrocardiogram changes such as bundle branch block or intraventricular conduction delay. If you have heart failure, your physician can readily tell you if you have this common abnormality. If present, electrical delay will adversely affect heart function resulting in inefficient pumping action of the heart. This electrical delay in the setting of heart failure is also associated with increase in the risk of death.

Recently, major advances have been made in technology that can overcome the problems created by the electrical abnormalities described above. Specifically, a therapeutic intervention termed "cardiac resynchronization" will reverse many or all of these abnormalities. Cardiac resynchronization is accomplished by a procedure called biventricular pacing. With this procedure, a standard two-wire pacemaker is placed in the right-sided cardiac chambers, and an additional wire is threaded through the vein of the heart to the left lower chamber's freewall. By stimulating the right and left-sided chambers simultaneously, the heart walls are "resynchronized". When this is accomplished, the vast majority of patients have improved cardiac function and reversal of the clinical consequences created by bundle branch block. The procedure can be successfully performed in 85-95% of patients with a risk of about 1%.

Clinical trials studying thousands of patients have been completed and published. They indicate significant improvement in overall heart failure outcome in patients treated with biventricular pacing devices. Patients report improvement of symptoms and exercise capacity. The hospitalization rates were also reduced.

Many patients with heart failure also face a risk of potentially fatal heart rhythms and sudden cardiac arrest. When this occurs, unless a patient is rapidly resuscitated, sudden death usually results. Standard treatment for a patient at high risk of sudden cardiac arrest is an implantable cardiac defibrillator. Biventricular pacing systems can be combined with the implantable defibrillator in appropriate patients to accomplish the dual desirable endpoints of improving heart failure and preventing sudden death.

Length of Procedure: Approximately 2 - 3 hours

Patients who have an unsuccessful implantation attempt of a biventricular pacing system due to unsuitable heart anatomy, may need placement of the third lead surgically directly on the heart surface. This is generally done by a Heart surgeon in the operation theater of a separate day. This lead is then tunneled and attached to the defibrillator/pacemaker