Cardiac Device Implantation

Cardiac implantable electronic devices (CIEDs) are well-established therapies for a wide range of cardiac arrhythmias. Permanent pacemakers restore effective circulation and close to normal hemodynamics by regulating heart rate and heart rate response. Antitachycardia pacing (ATP) for ventricular tachycardia (VT) termination and high-voltage shock are provided by implantable cardioverter defibrillators (ICDs), which are used to defibrillate ventricular fibrillation (VF) or cardiovert ATP-refractory ventricular tachycardia. In addition to correcting inter-and intraventricular desynchrony, cardiac resynchronization therapy (CRT) or biventricular devices have all of the features of standard pacemakers and ICDs. Since Dr. Senning implanted the first pacemaker in a person in the1950s, there have been significant advancements in CIED technology, including smaller size, longer battery life, and remote monitoring capabilities, as well as the incorporation of MRI-compatible CIEDs.

What are the Pacemakers?

Pacemakers are electronic devices that can be implanted in the body, usually during surgery, to help support the heart's electrical system. They can prevent problems that can destabilize or endanger life by stabilizing aberrant cardiac rhythms.

How Do Pacemakers Work?

Your heart has its own electrical system that tells the chambers of the heart when it's time to squeeze. When the heart's electrical system fails, the chambers of the heart may contract in the wrong order or too weakly to supply adequate blood to the body. Electrical impulses are used by pacemakers to correct various types of problems.

Cardiac Pacemaker Indications

Pacemakers are used to treat a variety of diseases. The following are just a few of the conditions that can be treated with a pacemaker:

Certain heart arrhythmias (abnormalities in the heart's normal beating mechanism).
The electrical system of the heart is disrupted (such as heart blocks).
Heart failure.
Heart attack history.

The first step in identifying if you have medical conditions that can be managed with a pacemaker is to speak with the healthcare professional about your worries or symptoms. The following are some of the symptoms you should discuss with your doctor:

Chest pain (referred to as angina).
Tachycardia is a heartbeat that is unusually quick (more than 100 beats per minute).
Bradycardia is a heartbeat that is unusually slow (fewer than 60 beats per minute).
Irregular heartbeat (arrhythmia).
Heart palpitations (for example, it may feel like it's flip-flopping or pounding in the chest).
Breathing difficulties, particularly when you are more active.
Dizziness or lightheadedness, nausea, or fainting.
Confusion with no apparent reason.
The ankles, legs, and abdomen are swollen.
Having to urinate several times during the night (nocturia).

Pacemakers Types

A specific type of pacemaker with anywhere from one to three wires (called leads) may be utilized depending on the cardiac issue. Pacemakers come in a variety of shapes and sizes.

A leadless pacemaker. It is a little pacemaker that is implanted through a catheter. Because this tool is linked to the internal wall of the heart, it does not require any wires.
Single-chamber pacemaker. A single wire is linked to one ventricle of the heart.
Dual-chamber pacemaker. Two wires are linked to two ventricles of the heart.
Biventricular pacemaker (cardiac resynchronization treatment). It has three wires, two of which link to the lower chambers of the heart (ventricles) and the third to the right upper chamber.

A similar device known as an implantable cardioverter-defibrillator (ICD) may be recommended by the healthcare professional. Despite the fact that it is not a pacemaker, they are frequently used to treat similar heart disorders such as ventricular fibrillation and ventricular tachycardia.

What is the Difference Between a Pacemaker and an ICD?

A pacemaker sends electrical impulses to the heart to regulate its rhythm, but it can't give you a shock to fix an arrhythmia.

The majority of modern implantable cardioverter defibrillators (ICD) can act as a pacemaker and detect hazardous heart rhythms. The ICD can give a shock to reset the heart's regular rhythm if these are recognized.

Cardiac Pacemaker Implantation Procedure

Depending on the type of pacemaker you have, you'll be addressed with a catheter, through a vein, or with a surgical procedure. These methods have been improved as surgical expertise has advanced. The idea is to make you experience less discomfort, recover faster, and return to the normal routine faster.

Catheter-based approach. This approach is utilized with leadless pacemakers, which exclusively treat issues that affect one chamber of the heart. A catheter is inserted into an artery (typically near the groin) and threaded up to the heart by a specialist. It's linked to the heart's wall once inside.
Transvenous approach. In adults, the transvenous (via a vein) technique is commonly utilized. A doctor makes a small cut near the heart to reach a vein during this technique. A vein that travels beneath the collarbone, to the arm, or to the neck is usually this vein. The specialist inserts the lead (wire) into the vein and connects them to a location on the heart using fluoroscopy (a form of X-ray). The pacemaker device will then be connected to the lead, which will be implanted in a small pocket beneath the skin of the upper chest.
Surgical (epicardial) approach: A surgeon makes a small cut in the chest, implants the lead(s), and then connects the lead(s) to the heart through that cut. The pacemaker is subsequently connected to the lead(s) by the surgeon. The pacemaker is placed beneath the skin of the abdomen in a pocket.

Catheter-based procedures take an hour or less to complete. The transvenous and surgical techniques take two to five hours to complete. The doctor will tell you which option is better for you.

Cardiac Pacemaker Benefits

Pacemakers are designed to improve your quality of life and prevent cardiac problems from disrupting your life. The following are some of the advantages:

Many of the symptoms associated with heart rhythm issues, such as chest pain, disorientation, palpitations, nausea, and bewilderment, are alleviated.
Arrhythmias can induce unpleasant symptoms such as fainting, which can be avoided.
By keeping the heart from dying, you can save your life.

Cardiac Pacemaker Risks

Pacemaker procedures have a low risk of problems, which you should discuss with your doctor. The following problems are probable in general:

Allergic reaction. Allergic responses can occur as a result of a drug you have been given or as a result of an allergy to one of the materials used in the pacemaker.
Blood clots. To lower the chance of a blood clot, the healthcare practitioner may prescribe blood-thinning drugs.
Pacemaker or lead malfunctions. A pacemaker lead may get jostled out of place or break free in some scenarios. To avoid this, the healthcare practitioner will advise you to limit your activities for a bit following the procedure.
Malfunctions brought on by exogenous influences. To avoid pacemaker issues faced by outside electrical interference, your healthcare professional will give you guidelines on which devices or machinery to avoid. Fortunately, thanks to developments in pacemaker technology, such scenarios are rare.
Unexpected heart rhythm abnormalities. Pacemakers have been known to induce heart rhythm problems in some patients. The healthcare professional can discuss these dangers with you and guide you to avoid them.

Implantable Cardioverter Defibrillator

A small electronic device attached to the heart is known as an implantable cardioverter-defibrillator (ICD). It is used to monitor and help manage potentially life-threatening electrical abnormalities in the heart continually.

A transvenous or conventional ICD is implanted beneath the skin right below the collarbone, about the size of a wristwatch. It is made up of a signal generator and wires known as leads. The battery and a little computer are both housed in the signal generator. The pulse generator is connected to particular areas in the heart by one or more lead wires.

When the ICD detects abnormal life-threatening heart rhythms in the lower chambers of the heart, it either uses pacing to adjust the fast rhythm and maintain a normal heartbeat, or it uses a shock (defibrillation) to restore the heart rhythm and prevent sudden cardiac death. For your doctor's review, an ICD also collects and retains information about the heart rhythm and therapies administered by the ICD.

When the ICD is pacing the heart, most people are completely unaware. However, many people report a defibrillation shock as a kick in the chest. When necessary, an ICD can be programmed to function as a basic pacemaker. The heart may sometimes beat too slowly after receiving a shock. The ICD features a backup pacemaker that can drive the heart to beat faster until it returns to its regular rhythm. When the heart rate falls below a certain level, the ICD can serve as a pacemaker.

A Subcutaneous Implantable Defibrillator (S-ICD) is available for patients who do not need backup pacing or Anti-Tachycardia Pacing. It permits high-energy shocks to be delivered while avoiding the hazards and issues associated with leads that pass into the veins leading to the heart.

Implantable Cardioverter Defibrillator Indications

If you have suffered abrupt cardiac arrest owing to ventricular fibrillation, collapsed due to ventricular arrhythmias, or have certain inherited heart disorders, you may require an ICD.

For patients who are at high risk of asystole due to ventricular arrhythmia, an ICD is typically required. People with cardiac failure who have issues with cardiac contraction, like an abnormal left ventricular ejection fraction, fall under this category. Your doctor may recommend an ICD for a variety of reasons.

ICD Implantation Preparation

The doctor will take you through the procedure and ask you if you have any concerns. You will be asked to sign a consent form indicating that you agree to participate in the test. If something is unclear, read the form carefully and ask questions. If you are allergic to or sensitive to any drugs, iodine, latex, tape, or anesthetic agents, talk to your doctor.

Before the procedure, you will need to fast for a predetermined period of time. The doctor will advise you on how long you should fast, which is usually overnight. Notify the doctor if you are pregnant or suspect you might be. Tell the doctor about any medications you're taking, including prescription and over-the-counter medications, as well as herbs or other supplements.

If you have heart valve disease, tell the doctor since you may need to take an antibiotic before the implantation. If you have a history of bleeding issues or are using any blood-thinning medications (anticoagulants), aspirin, or other blood-clotting medications, tell the doctor. Before the surgery, you may be told to cease taking some of these medications.

Before the surgery, the doctor may order a blood test to evaluate how long it takes the blood to clot. Additional blood tests and a chest X-ray may be required. Before the procedure, you may be given a sedative to calm you down. The doctor may require further preparation depending on your health condition.

ICD Implantation Procedure

An ICD can be put either as an outpatient procedure or as part of hospital admission. Procedures may differ depending on your situation and the practice of your doctor. In general, an ICD insertion goes like this:

You'll be asked to take off any jewelry or other items that might get in the way of the operation.
You'll be asked to take off your clothes and given a gown to put on.
Before the procedure, you will be advised to empty your bladder.
If necessary, an intravenous line will be started in your hand or arm to provide medicine and fluids.
You will be positioned on your back on the operation table.
During the operation, you will be linked to an electrocardiogram (ECG) monitor, which will record the electrical activity of your heart. During the procedure, your vital signs (heart rate, blood pressure, respiratory rate, and oxygen saturation level) will be monitored.
The surgery site is cleansed. Hair may be shaved or cut in some instances.
Large electrode pads will be inserted on the front and back of the chest.
Before the treatment, you will be given a sedative through your Intravenous line to help you relax. You will, however, most likely be conscious throughout the procedure.
Antiseptic soap will be used to clean the ICD insertion site.
This area will be surrounded by sterile towels and a sheet.
A local anesthetic will be administered to the skin.
The doctor will make a small cut at the insertion site after the anesthesia has taken effect.
A sheath, also known as an introducer, is placed into a blood vessel, typically beneath the collarbone. The ICD lead wire will be placed into a blood vessel and moved into the heart through the sheath, which is a plastic tube.
It is essential that you remain completely motionless throughout the procedure to ensure that the catheter does not slip out of place and that the insertion site is not harmed.
The introducer will be used to put the lead wire into the blood vessel. The doctor will insert the lead wire into the heart through a blood vessel.
The lead wire will be tested once it has been placed into the heart to ensure that it is in the correct place and that it functions properly. Depending on the type of device your physician has chosen for your disease, one, two, or three lead wires may be implanted. The lead will be placed using fluoroscopy (a specific form of X-ray that will be exhibited on a TV monitor).
One or two tiny cuts are made close the top and bottom of the sternum or breastbone for subcutaneous ICD. The lead wire is then tunneled beneath the skin near to the sternum and from the sternum to the left-side chest cut.
After the lead wire is linked to the generator, the ICD generator will be inserted under the skin through the cut (just below the collarbone for conventional ICD and on the left side of the chest for S-ICD). If you're a right-handed person, the gadget will usually be put in the upper left chest. S-ICDs are placed near the heart on the left side of the chest. A conventional ICD can be implanted in the upper right chest if you are left-handed or have a contraindication to a left-sided device.
The ECG will be monitored to see how well the ICD is working. The device's functionality may then be evaluated using a number of tests. Sutures, adhesive strips, or special glue will be used to seal the skin cut. A sterile bandage is a bandage that has been sterilized.

Implantable Cardioverter Defibrillator Risks

The following are some of the hazards associated with ICD implantation:

Bleeding at the location of the incision or catheter installation
Injury to the blood vessel at the insertion location of the catheter.
Infection at the site of the cut or catheter
The cardiac muscle is torn.
Lung collapse.
The leads became dislodged, necessitating a second treatment to reposition them.

Implantable Loop Recorder

If you've been having repeated episodes of loss of consciousness, palpitations, lightheadedness, or dizziness, the doctor may recommend an implantable loop recorder (ILR).

An implantable loop recorder is a tiny, thin device that is implanted beneath the skin and monitors and records the electrical activity of the heart over an extended period of time in order to detect an abnormal cardiac rhythm. The ILR can tell you if your symptoms are caused by a cardiac rhythm issue.

Implantable Loop Recorder Indications

If you're having fainting episodes or palpitations and prior tests haven't given you any answers, you could need a loop recorder. Fainting on a regular basis can have a detrimental impact on your physical and mental health. Additionally, certain types of fainting dramatically enhance the chances of dying suddenly. These episodes of fainting must be diagnosed and treated as soon as feasible. You may need a pacemaker or an implantable cardioverter-defibrillator (ICD) if you've been diagnosed. These have the potential to save your life. If your healthcare professional wishes to look for particularly fast or slow heart rhythm, you may additionally need a loop recorder. These irregular heartbeats might result in palpitations or even strokes.

If you're having trouble with fainting, the doctor will look into a variety of factors. Only a few types of fainting are caused by irregular cardiac rhythms. Your doctor will most likely start with simple tests like an electrocardiogram (ECG). However, this only records the heart rhythm for a few seconds. As a result, it's possible that the healthcare professional won't be able to pinpoint the precise rhythm issue that's causing your fainting. Other diagnostics, such as Holter monitoring, tilt-table testing, or electrophysiologic studies of the heart, may have been tried.

If prior testing has failed to find the cause, a loop recorder may be implanted. If the heart is a potential cause of your fainting, your doctor is more likely to suggest it. This occurs more frequently in the elderly. It's also more likely in persons who already have a heart condition. If you faint repeatedly but not often enough for other types of heart rhythm monitoring to identify your fainting, you may need a loop recorder implant. Your healthcare physician should ultimately be able to evaluate your heart rhythms during a fainting event because the loop recorder can record for up to three years.

If you're an older adult experiencing unexplained falls, you might also need a loop recorder. It's sometimes used by doctors to treat people with epilepsy who haven't responded to medication. In both circumstances, the recorder can tell if the problem is an irregular beat.

How Do I Prepare for a Loop Recorder Implantation?

Discuss what you should do to prepare for your procedure with your healthcare practitioner. It's possible that you won't be able to eat or drink anything after midnight the night before the procedure. Before the procedure, follow your healthcare provider's advice regarding what medications to take. If your provider advises you to stop taking a medication, don't. Before the procedure, he or she may order tests such as an ECG.

Implantable Loop Recorder Implantation

Implantable Loop Recorder implantation is a frequent operation. It's done with a local anesthetic and sedative drug to make you feel at ease. The operation is completed in the cardiac catheter laboratory and takes about 12-20 minutes. This is a unique room with a patient table, X-Ray tube, ECG monitor, and other medical devices. The lab workers will be outfitted in hospital theater attire and will be wearing hats and masks during the operation.

A number of ECG monitoring sensors will be placed on the chest. An intravenous line is normally inserted into the back of your hand by a nurse or doctor. This is required as a dependable method of administering medications such as antibiotics and painkillers.

A particular sterile solution is used to prepare the region, which may feel cold. A wide sterile sheet will be draped over you, partially covering your face. A nurse will be present at all times and you will be able to look out from under the sheet to the side. A tiny tube inserted into the nostrils or a mask covering your face will provide you with oxygen to breathe.

A tiny incision in the chest wall is created. To fit the device, a tiny pocket is created beneath the skin. Dissolvable sutures are used to seal the wound once the gadget is put into the pocket. A little scar will be visible at first, but it will diminish with time.

The device, which sits in the tissue over the heart like an ECG, can take up electrical activity from the heart from the outside of the chest without any wires.

Implantable Loop Recorder Risks

The majority of people go through the surgery without any issues. However, problems can develop from time to time. These could include the following:

Bruising or bleeding
Infection
The heart or blood vessels may be injured.
Mild discomfort at the implantation site

Your own risks will be determined by your age, medical history, and other factors. Inquire with your healthcare practitioner about any potential dangers associated with the operation.

Conclusion

Cardiac implantable electronic devices (CIEDs) are rechargeable battery-powered medical devices that help patients with conduction problems or heart failure control and/or monitor arrhythmias. For regulating arrhythmias, CIEDs include artificial cardiac pacemakers, implantable cardioverter defibrillators (ICDs), cardiac resynchronization therapy (CRT) devices, and left ventricular assist devices, as well as implantable cardiac monitors (loop recorders).