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 MEDICAL SERVICES

CARDIOVASCULAR TREATMENT

Cardiac Implantable Electronic Devices (CIEDS)

CARDIAC IMPLANTABLE ELECTRONIC DEVICES (CIEDS)

(Recommend review “Arrhythmia Clinic” and “Heart Failure Clinic”)


WHAT IS CARDIAC IMPLANTABLE DEVICES?

Small electronic devices that can be inserted into the patient body to treat or support specific heart conditions.


CARDIAC IMPLANTATION DEVICES

 
  1. Pacing/Defibrillation for specific cardiac arrhythmias
    1. Pacemaker
    2. ICD (Implantable Cardioverter Defibrillator)
    3. Combine device (such as CRT-D, CRT-P) 
  1. Improve/support heart pumping function
    1. CRT (Cardiac Resynchronization Therapy or Biventricular pacemaker)
    2. LVAD (Left Ventricular Assist Device)



PACEMAKER

   
CRT (CARDIAC RESYNCHRONIZATION THERAPY OR BIVENTRICULAR PACING)
   
ICD (IMPLANTABLE CARDIOVERTER DEFIBRILLATOR)
 
 
PACEMAKER

WHAT IS PACEMAKER?

Pacemaker is a small implantable battery operate device that can discharge small direct electrical current to stimulate the heart to initiate heartbeat. It indicates in patient with potentially dangerous slow or absent heartbeat. Current pacemaker can be very sophisticated and has multiple functions to make it work as close to human heart electrical system as possible. It can record and store heart electrical activities that can accurately diagnosis the heart abnormal rhythm (arrhythmia).

Pacemaker
 
PACEMAKER COMPONENT
 
  1. Pulse generator
 
  • Size and shape (as shown in the picture)
  • Pulse generator component (Electronic-circuitry, battery, connector)
  • There are many types and functions. The doctor will choose the types that suit you the most.
 
  1. Lead
  • Conducting metal coil insulated with silicone or polyurethane, which will connect pulse generator to the specific heart position.
  • 1-3 leads are required depends on which type of pacemaker.
 
 
INDICATION

(More detail on electrical system of the heart in Arrhythmia Clinic)
  • Bradycardia (slow heart beat or pause)
    • Sinus node or other natural pacemaker dysfunction
    • Heart electrical conducting system malfunction particularly blocking the electrical impulse.
  • Indication of CRT (Cardiac resynchronization therapy or biventricular pacing) is for improving heart-pumping chamber to pump blood more efficiently.
  • There are few other conditions that your doctor may recommend pacing to you. You will have to discuss the benefit with your doctor.
 
TYPE OF PACEMAKER
 
  1. Type of heart chamber involve
 
  • Single chamber
  • Two or dual chambers
  • Three chambers in case of CRT or biventricular pacing
 
  1. Type or mode of function
  • Fixed rate; demand mode; rate responsive
 

WHERE IS IT DONE?


            Cardiac catheterization or electrophysiology laboratory
 

WHAT TO EXPECT DURING PACEMAKER SURGERY?
 
  • Minor surgery. Use local anesthesia. Should be painless or only minor discomfort after local anesthesia.
  • Small incision (cut) over the upper chest, about 2 inches. Prefer opposite side from hand preference.
  • Subcutaneous pocket creation
  • Leads were placed into a vein under the collarbone then advance into the heart position under fluoroscopic guidance.
  • Check leads parameters
  • Leads connect to the pulse generator
  • The pulse generator with connected leads was inserted into the pocket that has been created
  • Closing the incision
  • Procedure time 1-2 hours
 
WHAT TO EXPECT AFTER PACEMAKER SURGERY?
 
  • Expect to stay in the hospital overnight so your health care team can check your heartbeat and make sure your pacemaker is working well.
  • You'll likely have to arrange for a ride to and from the hospital.
  • Keep your wound clean and dry. Look at your wound every day to make sure it is healing properly. Call your doctor if you notice:
    • Increased drainage, bleeding, or oozing from the insertion site
    • Opening of the incision
    • Redness around the site
    • Warmth along the site
    • Increased body temperature (fever or chills)
  • For a few days after surgery, you may have mild pain, swelling, or tenderness in the area where your pacemaker was placed.
  • Most people return to their normal activities within a few days to few weeks of having the surgery.
  • Avoid vigorous activities and heavy lifting for about a month after pacemaker surgery.
  • You should carry pacemaker ID card with your pacemaker information all the time.
 
WHAT ARE THE RISKS OF PACEMAKER SURGERY?

 
Pacemaker surgery generally is usually safe. If problems do occur, they may include:
  • Swelling, bleeding, bruising in the area where the pacemaker was placed
  • Blood vessel or nerve damage
  • A collapsed lung
  • Lead dislodgement require repositioning
  • Infection relate to pacemaker and lead
 
The serious complications for example death or perforation of cardiac chamber is low.
Talk with your doctor about the benefits and risks of pacemaker surgery.
 

HOW WILL A PACEMAKER AFFECT MY LIFESTYLE?

 
Once you have a pacemaker, you have to avoid close or prolonged contact with electrical devices, devices that have strong magnetic fields. Devices that can interfere with a pacemaker such as cell phones and MP3 players, microwave ovens, high-tension wires, metal detectors, industrial welders and electrical generators.
Medical procedures that may affect the pacemaker
 
  • Magnetic resonance imaging, or MRI
  • Electrocauterization to stop bleeding during surgery
  • Shock-wave lithotripsy to get rid of kidney stones
You can walk through security system metal detectors at your normal pace.
 
 
LONG TERM CARE
 
  • In most cases, having a pacemaker won't limit you from doing sports and exercise, except for heavy contact sport
  • Regular pacemaker check up every 3 to 6 months
 
 
BATTERY REPLACEMENT

Pacemaker batteries last between 8 and 15 years, depending on how active the pacemaker is. Your doctor will replace the pulse generator before the battery starts to run down.

Replacing the pulse generator and battery is less-involved surgery than the original surgery to implant the pacemaker. Your pacemaker leads also may need to be replaced eventually.
 


CRT (CARDIAC RESYNCHRONIZATION THERAPY OR BIVENTRICULAR PACING)


WHAT IS CRT?

Pacemaker system designed to help heart failure patients to pump blood more efficient. Some of the weak-pumping chamber, the left bottom chamber, develops non-uniform contraction of the chamber wall. This pacing system require additional lead to also pace the heart opposite from the standard position. The standard position is usually the right ventricular apex and the opposite site is the left ventricle from epicardial side (pacing from coronary vein).
  • Preparation is similar to the pacemaker system mention above.
  • Operation usually takes longer time for placing the “left ventricular” lead.

INDICATION
 
  • Heart failure with poor left ventricular pumping function (Heart failure with reduced ejection fraction - HFrEF)
  • Indication has been gradually evolving over the years
 
* Despite optimal medical therapy
 
(SIMILAR TO PACEMAKER)
WHERE IS IT DONE?
WHAT TO EXPECT DURING CRT SURGERY?
WHAT TO EXPECT AFTER CRT SURGERY?
WHAT ARE THE RISKS OF CRT SURGERY?
HOW WILL A CRT AFFECT MY LIFESTYLE?
LONG TERM CARE
 
BATTERY REPLACEMENT
  • The above activities for the CRT system is similar to the regular pacemaker system.
  • Patients who require CRT are usually have more activity limitation due to underlying disease (heart failure)


ICD (IMPLANTABLE CARDIOVERTER DEFIBRILLATOR)



WHAT IS ICD?

An implantable cardioverter defibrillator (ICD) or automated implantable cardioverter defibrillator (AICD) is a device implantable inside the body, able to perform both cardioversion (convert the abnormal fast heartbeat back to normal), defibrillation (delivering shock to stop fatal fast heartbeat) and pacing of the heart (when the heart is beating too slow or no heartbeat). The device is therefore capable of correcting most life-threatening cardiac arrhythmias. The ICD is the first-line treatment and prophylactic therapy for patients at risk for sudden cardiac death (SCD) due to ventricular fibrillation and ventricular tachycardia.[1] Current devices can be programmed to detect abnormal heart rhythms and deliver therapy via programmable antitachycardia pacing (ATP) in addition to low-energy and high-energy shocks.
 

TYPES
 
  • Single chamber ICD, requires one lead in the right ventricle.
  • Dual chamber ICD, require 2 leads, one in the right ventricle and the other  in the right atrium.
  • Biventricular ICD or CRT-D 3 leads, one in the right ventricle, another one in the right atrium and the other in the coronary vein outer wall of the left ventricle.
  • Subcutaneous ICD, the newest system that do not require insertion of the lead into the heart. The whole system is in subcutaneous layer over the chest.
 
INDICATION
 
  • Have had a life threatening ventricular arrhythmia before.
  • Have survived sudden cardiac arrest (SCA).
  • Heart failure with poor pumping function (low left ventricular ejection fraction). Some patients will be benefit from combined CRT and ICD.
  • Have certain heart conditions that put them at high risk for SCA. For example, people who have long QT syndrome, or Brugada syndrome
  • The indication may be divided into primary and secondary prevention of SCA.
 
  1. Primary prevention: Refers to patients who have not suffered a life-threatening arrhythmia episode yet.
 
  • In patients with LVEF ≤ 35% due to prior MI who are at least 40 days post-MI and at least 90 days postrevascularization, and with NYHA class II or III HF despite guideline directed medical therapy (GDMT)
  • In patients with LVEF of ≤ 30% due to prior MI who are at least 40 days post-MI and at least 90 days postrevascularization, and with NYHA class I HF despite GDMT
  • In patients with nonischemic cardiomyopathy (NICM), HF with NYHA class II-III symptoms and LVEF ≤ 35%, despite GDMT
 
  1. Secondary prevention: Refers to patients who have suffered a life-threatening arrhythmia episode or SCA.
 
  • In patients with ischemic heart disease, who either survive SCA due to VT/VF or experience hemodynamically unstable VT or stable VT not due to reversible causes, an ICD is recommended if meaningful survival greater than 1 year is expected
  • In patients with ischemic heart disease and unexplained syncope who have inducible sustained monomorphic VT on electrophysiological study, an ICD is recommended if meaningful survival of greater than 1 year is expected
  • Patients with NICM who either survivor SCA due to VT/VF or hemodynamically unstable VT or stable VT not due to reversible causes, an ICD is recommended if meaningful survival greater than 1 year is expected
 
(Similar to Pacemaker)
WHERE IS IT DONE?
WHAT TO EXPECT DURING ICD SURGERY?
WHAT TO EXPECT AFTER ICD SURGERY?
WHAT ARE THE RISKS OF ICD SURGERY?
HOW WILL A ICD AFFECT MY LIFESTYLE?
LONG TERM CARE
BATTERY REPLACEMENT
  • The above activities for the ICD system is similar to the regular pacemaker system.


LIVING WITH AN ICD

People who have an implanted cardioverter-defibrillator can live full lives. Usually the ICD may not improve the quality of life of the patient, although it may provide a strong degree of reassurance. As with a pacemaker, however, living with an ICD does impose some restrictions on the person's lifestyle, outlined below.

UNNECESSARY (FALSE) ELECTRICAL ICD SHOCK DELIVERING

Implantable cardioverter defibrillators (ICDs) can sometimes give electrical shocks that aren't needed. A damaged wire or a very fast heart rate due to extreme physical activity may trigger unnecessary shocks. Your doctor will be able to help prevent these false shocks.

PHYSICAL ACTIVITIES

Almost all forms of physical activities can be performed by patients with an ICD. All forms of sports that do not pose a risk of damaging the ICD or because of the underlying cardiomyopathy can be undertaken by the patient. Special care should be taken not to put excessive strain on the shoulder, arm and torso area where the ICD is implanted.

ELECTRO-MAGNETIC EQUIPMENT

Equipment using large magnets or generating magnetic fields, or any similar environment, must be avoided by patients with an ICD. As with other metallic objects, an ICD is a contraindication to the use of magnetic resonance imaging (MRI). However, if the implanted system was MRI compatible, the patients are able to get into the scan after it is reprogrammed.

DRIVING

You'll have to avoid driving for at least a week while you recover from ICD surgery. If you've had sudden cardiac arrest (SCA), a ventricular arrhythmia, or certain symptoms of a ventricular arrhythmia (such as fainting), your doctor may ask you to not drive until you have gone 6 months without fainting. Some people may still faint even with an ICD.
Commercial driving isn't permitted with an ICD.
 
 
 
MECHANICAL CIRCULATORY SUPPORT (MCS)

BIVAD (BIVENTRICULAR ASSIST DEVICE) OR LVAD (LEFT VENTRICULAR ASSIST DEVICE)



For patients with either chronic or acute HF who cannot be stabilized with medical therapy, mechanical circulatory support systems can be used to unload the weak ventricle and maintain sufficient cardiac output. Patients with chronic, refractory HF despite medical therapy can be treated with a permanent LVAD.