Arrhythmia Associates LLP

Process - Procedures

Procedures

Exercise Stress Test

The exercise test (on a treadmill) is especially useful for arrhythmias experienced only during exercise. The patient wears several electrodes attached to an ECG machine and walks progressively faster on the treadmill. This is also a way of evaluating whether or not coronary artery blockages are present.

Preparation
Do not eat or drink anything after midnight the evening before your procedure. If you must take medications, drink only small sips of water to help you swallow your pills.

Take all your medications as prescribed. If you are diabetic, check with the office about how to adjust your diabetic medications.

Wear comfortable clothes and shoes for walking. You will wear a hospital gown during the procedure. It is best not to wear any jewelry or valuables. Electrode patches will be attached to your chest and upper back. Men may have their chest hair shaved for electrode placement. A blood pressure cuff will be attached to your arm for monitoring during this test.

Procedure
The nurse will help you to the treadmill machine and the physician or physician's assistant will slowly start the treadmill belt and you will start walking at a comfortable stride. Every three minutes, the treadmill will move faster and the incline of the treadmill will increase. We will encourage you to walk for as long as possible so that we can obtain the maximal amount of information about your heart. When you feel that you can no longer continue, you will notify us and the treadmill will slow down and return to a flat level and then the treadmill belt will stop. We will help you back to the examining table as you may feel slightly dizzy. Your heart rate and blood pressure will continue to be monitored until your heart rate and blood pressure return to normal.

Follow-up care
The results of your treadmill test will be discussed with you and further recommendations will be made. As always, if you have any further questions, don't hesitate to call our office.

Microvolt T-Wave Alternans

There are two methods to perform m-TWA testing: exercise/walking testing and pacing testing. With a walking test, you will walk on a treadmill to slowly raise your heart rate to a rate greater than 100 beats/min. If your resting heart rate is already 100 beats/min, then walking may not be necessary.

A pacing test is generally performed in patients who already have a pacemaker. After the electrodes are correctly placed, the pacemaker is interrogated and we will temporarily program it to a set rate of 110 beats/min.

In either case, the data is obtained and then processed by a machine and the results will be interpreted by your doctors. The testing itself takes approximately 10 minutes. The interpretation of the test can sometimes be hindered by extra heart beats called atrial premature contractions (see APC's) or ventricular premature contractions (see VPC's) and the testing may need to be repeated for another 10 minutes.

Holter Monitor Placement

Holter monitoring is a continuous recording of an ECG for 24 hours. If prescribed by our physicians at the time of your office visit, the nurse will apply electrodes on the skin's surface to continuously record the heart's electrical activity, and the signals are saved and later analyzed. You will wear the monitor for 24 hours continuously and we ask that you do not take off the device during that time so that all of the information is available for our review. You will be given a form to allow you to document any symptoms that occur while you wear the Holter monitor. Please write down the time of your symptoms and try to describe what you are feeling (i.e. "palpitation", "lightheadedness", "dizziness", "heavy beats"). This information will greatly help us interpret the study.

The following day, you will bring back the monitor and the nurse will help you take off the device for analysis. The information will be reviewed by our physician in the office that day and we will contact you by the following day to discuss any further recommendations.

Event Recorder Placement

The event recorder is a kind of Holter that is a continuous loop-recording device. It can be "worn" for a whole month and the patient alerts the device when an arrhythmia symptom appears by pushing a button. The saved signals can be transmitted over a telephone to the doctor's office for analysis. If prescribed by our physicians at Arrhythmia Associates, our nurse will teach you how to apply the device to record the electrical signals of your heart when you have symptoms. This device can be taken off at night and you may take a shower when the recorder is not attached. This device can record for up to 30 days but information will only be obtained if you instruct the device to record. At the end of 30 days, we will ask you to return to our office visit to discuss the results of this testing. Our physicians will then make additional recommendations.

What To Expect From Hospital Procedures

Pacemaker Implantation

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.

ICD Implantation

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.

Device Generator Change

All implantable devices such as pacemakers and ICDs run on lithium-type batteries and these batteries will eventually become depleted. Your physicians at Arrhythmia Associates will identify this either during routine office visits or by specific findings on routine "trans-telephonic" testing. When the battery on your implanted device is beginning to deplete, the device has reached an "elective replacement indication" and this is the standard time to have the battery changed. All modern pacemaker and ICDs have the battery soldered to the device itself and therefore the entire device will be replaced with a new one.

Preparation
Do not eat or drink anything after midnight the evening before your procedure. If you must take medications, drink only small sips of water to help you swallow your pills.

Take all your medications as prescribed. If you are diabetic, check with the office about how to adjust your diabetic medications. If you are on a blood thinner (anticoagulant), we may give you specific directions regarding this medication for the procedure, and the weeks leading up to the procedure.

Wear comfortable clothes. You will wear a hospital gown during the procedure. It is best not to wear any jewelry or valuables.

Most likely, you will be able to go home after the procedure. You should bring someone with you to drive you home after the procedure.

Procedure
You will lie on a bed and the nurse will start an intravenous (IV) line into your arm or hand. This is so you may receive medications and fluids during the procedure.

The nurse will bring you to the electrophysiology laboratory and connect you to several monitors. Electrode patches will be attached to your chest and upper back. Men may have their chest hair shaved for electrode placement. A blood pressure cuff will be attached to your arm. Your heart rate and blood pressure will be carefully monitored. You will receive mild sedation by an anesthesiologist but you will be breathing on your own.

Your physician at Arrhythmia Associates will position surgical drapes around the skin incision just above your device to minimize any chance of infection. IV antibiotics will then be administered and a Novocain-type medication will be administered into the region of your previous surgical scar to numb the skin. We will then open the previous incision and identify the implanted device and remove it from the body. The wires are then detached from the device and the wires themselves are tested to make sure that they are functioning normally. If the wires are working normally, a new device is brought to the operative field and attached to the indwelling wires and the device is re-inserted into the body. The incision is then closed using restorable sutures and a bandage will be applied to the skin. This procedure takes about 30-40 minutes.

Recovery
After the procedure, we will bring you to a recovery area for observation. We will provide you a prescription for additional antibiotics and any additional pain medications that you require. You will be observed clinically and when you feel well the IV will be removed from your arm and you will be sent home.

Follow-up care
We will make an appointment to see you in our office in 10 days or so. We generally request that you return to the hospital the following morning at 9-10am for one of the physicians to briefly evaluate your incision.

As always, if you have any questions, please call our office.

Tilt Table Test

You will lie on a bed and the nurse will start an intravenous (IV) line into your arm or hand. This is so you may receive medications and fluids during the procedure.

The nurse will connect you to several monitors. Electrode patches will be attached to your chest and upper back. Men may have their chest hair shaved for electrode placement. A blood pressure cuff will be attached to your arm. Your heart rate and blood pressure will be carefully monitored while you are resting. We will then raise the table to a 70 degree incline. You may feel like you are falling forward but you will be strapped to the table to prevent this. Your blood pressure and heart rate will be carefully monitored. We will ask you to inform us if you feel dizzy or lightheaded. If you begin to feel symptoms, we will watch your blood pressure and heart rate even more closely to understand the mechanism for your dizziness. If the symptoms become worse, we will put the table back down flat and we will increase the fluids going into your arm and your symptoms should rapidly resolve.

Cardiac Electrophysiology Study

As many as four catheters will enter the veins and, guided by the fluoroscope, they will be placed within the various areas of the heart. These catheters will record the heart's electrical signals as well as stimulate the heart to beat with tiny electrical currents transmitted through the electrode catheters. In this way your arrhythmia will be stimulated to start and computerized mapping technique will identify the source of the arrhythmia. Occasionally, the arrhythmia you experienced will not be inducible. In this circumstance, your doctors will administer intravenous drugs which are known to help induce arrhythmias. This constitutes the EPS procedure and its results determine if cardiac ablation is appropriate and feasible. For more information on the ablation procedure please see Treatment options, catheter ablation.

Catheter Ablation

In a similar way to a diagnostic electrophysiology (EP) study , catheters are placed intravenously and advanced to several positions within the right heart. These catheters can be used, as with the EP Study, to record from and stimulate the heart. These catheters can be manipulated throughout the heart in an attempt to identify the precise location from which an arrhythmia originates. Since most arrhythmias require a specific and usually small area of the heart in order to begin or continue, localization of these key, but vulnerable sites, could lead to elimination of the arrhythmia.

If these sites are identified, a catheter is moved to this area of the heart. The tip of a specially designed catheter placed in this position can be used to deliver energy (usually radiofrequency energy). This energy will heat up the adjacent tissue to the point of coagulation. The amount of tissue heated, however, is quite small. But if it includes the critical area for arrhythmia formation, this tissue can be permanently made nonfunctional and thus incapable of causing an arrhythmia.

This procedure lasts somewhat longer than the typical EP Study but ablation is the critical element for potential cure of many clinically important arrhythmias. Most often, patients go home the day of the procedure but occasionally we require an overnight hospital stay. The anticipated results of the procedure depend somewhat on the nature of the arrhythmia targeted. For the most common arrhythmias, the procedural success rate by our experienced operators is in the range of 90-99%. The risks of the procedure are generally small and often only related to intravenous puncture. Serious cardiac complications are uncommon, but can occur.