Centers of Excellence in Interventional Cardiology and Radiology

Electrophysiology

Implantable Defibrillator

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Generalities

Implantable Cardioverter Defibrillator

What is an ICD? An ICD (implantable cardioverter defibrillator) is an electronic device that constantly monitors your heart rhythm. When it detects a very fast, abnormal heart rhythm, it delivers energy to the heart muscle and this causes the heart to beat in a normal rhythm again. Why is an ICD needed? Ventricular tachycardia and ventricular fibrillation are two life-threatening heart rhythms that cause the heart to beat very fast. These conditions can be fatal if not treated immediately. Your doctor will recommended that you receive an ICD because if you have had at least one episode of these heart rhythms or are at high risk of developing these types of heart rhythms ( this two arrhythmias are symptomps of several heart disease).

How does an ICD work? As we pointed above, the ICD function like a monitor who identifies abnormal heart rhythms and determines the appropriate therapy to return your heartbeat to a normal heart rhythm. The ICD can have multiple functions, wich your doctor will choose according to your needs: •Anti-tachycardia pacing (ATP) – When your heart beats too fast, a series of small electrical impulses are delivered to the heart muscle to restore a normal heart rate and rhythm. •Cardioversion – if the device identifies an abnormal rhythm, a low energy shock (like a low intensity current) is delivered at the same time as your heartbeat to restore a normal heart rhythm. •Defibrillation – When the heart is beating dangerously fast, situation that can be life threateing, a high-energy shock is delivered to the heart muscle to restore a normal rhythm. •Bradycardia pacing – When the heart beats too slow, small electrical impulses are sent to stimulate the heart muscle to maintain a suitable heart rate.

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Contents of an ICD: 1. Pulse generator – houses the battery ( energy is stored in the battery until it is needed) and a tiny computer, who detects the abnormal heart rhythm, basing on the informations received from the leads 2. One or more leads – these are fixed in the heart’s cavities; these wires send informations to minicomputer, but also send informations from the pulse generator to the heart muscle in case of an abnormal rythm

Types of ICDs

•Single chamber ICD – has single lead, fixed in the right ventricle; if needed, energy is delivered to the right ventricle •Dual chamber ICD – in this case there two leads attached in the right heart (one lead in the right atrium, the other one in the right ventricle); the electric stimule is first delivered in the right atrium, then to the ventricle, helping the heart to contract nearly normal (in a normal sequence) •Biventricular – there are two leads (in wich case one of them has two wires for the right atrium and ventricle, and the second one is fixed in left ventricle via coronary sinus) or three leads (each for one heart cavity: right atrium, right ventricle, left ventricle; this kind of stimulation is also called cardiac resincronisation therapy); this device helps the heart beat in a more balanced way and is specifically used for some patients with heart failure ( CRT/ICD)

Normally, the two ventricles (the lower heart’s cavities) contracts simultaneous. In case of heart failure, these situation is no more available, meaning that the contraction is delayed between right and left ventricles, and that affect additional heart’s function (normally, heart is like a pump, sending the blood (an adequate quantity) in the body, mantaining a good function, but when we talk about heart failure the blood quantity is diminished, affecting the organs and causing symptomps like: chest pain, difficult breath, oedema, renal problems, dizziness). Biventricular stimulation restore the synchronous contraction of ventricles. There are some advantages of this kind of device ( biventricular device): improvement of heart failure ( more than 50% of patients despite maximal medical treatment, with intens symptomps), increase quality of life, but also the survival, increase the exertional capacity, decrease the need of hospitalization.

This combination ( def-biventriciular device) is helping maintaining a normal heart rythm (no matter if the heart is beatting to fast or to slow), but also a synchronous contraction of ventricles and is recording the heart rythm and the heart frequency.

Indications

There are two types of recommendations: primar pophylaxis ( preventing the first undesirable eveniment) and secondary prophylaxis (preventing undesirable eveniments after the first one already produced)

•patients who had a prior episode of sudden cardiac arrest

•patients who had a prior episode of ventricular fibrillation or at least one episode of ventricular tachycardia

•patients who had a prior heart attack and have an increased risk for sudden cardiac arrest or sudden cardiac death

•patients who have hypertrophic cardiomyopathy or other conditions witch associate abnormals hearth rhythms ( like : long QT syndrome)

•structural heart diseases

•syncope ( loss of consciousness) of unknowing cause and ventricular fibrilllation or tachycardia on electrophysiological study

•arrythmogenic right ventricular dysplasia

•patients waiting for cardiac transplant

•Brugada syndrome

•cardiac sarcoidosis, giant cell myocarditis, Chagas disease

Procedure

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The implant procedure takes place in a special room – the Electrophysiology Lab.

Device insertion is a minim-invasive procedure, meaning leads fixation in the heart’s cavities and then attaching them to the pulse generator, wich is implanted under the skin (most of the cases) or under the pectoral muscle.

To prevent infection and to keep the device insertion site sterile:

•You will receive an antibiotic through the IV at the beginning of the procedure.

•One side of your chest will be shaved.

•The area will be cleansed.

•You will be covered from your neck to feet with sterile drapes.

•A soft strap may be placed across your waist and arms to keep your hands from touching the sterile area.

The ICD is usually implanted using the endocardial (transvenous) approach. During the procedure, a local anesthetic (pain-relieving medication) is injected to numb the area. Small incisions are made in the chest where the lead(s) and device are inserted. The lead is inserted through the incision and into a vein, then guided to the heart with the aid of the fluoroscopy machine. The tip of the lead is attached to the heart muscle, while the other end is attached to the pulse generator. The generator is placed in a pocket created under the skin in the upper chest.

After the leads are in place, they are tested to make sure they are in the right place and working properly. This lead function test is called “pacing.” During the test, small amounts of energy are sent through the leads into the heart muscle. This energy causes the heart to contract. You will be asleep for several minutes during the lead function test.

Once the leads have been tested, the doctor will connect them to the device. The rate and settings of your device are determined by your doctor. After the implant procedure, the doctor uses an external device (programmer) to make the final device settings.

In rare cases when the endocardial approach cannot be used, the epicardial (surgical) approach is used. With this approach, you are put to sleep with general anesthesia. The generator is placed in a pocket created under the skin in the lower abdomen.

Is it painful?

The doctor will use local anesthesia, so the patient will not feel any pain, and after the procedure it will received pain drugs if needed (you may feel discomfort at the device implant for a few days). A medication will be given through your IV to relax you and make you feel drowsy, but you will not be asleep during the procedure.

How long does it take?

Usually, the device implant procedure may last from 1 to 4 hours and it takes place in a special room.

Risks

Complications are rare and the risk is decreased because the proper preparation and the permanent surveillance.

•damage to surrounding blood vessels, organs, or other structures by instruments

•wound infection or dehiscence, pocket hematoma

•bleeding

•pain

•allergic reaction or Immunologic rejection – Rare- rare

•fever

•abnormal function because of posibles complications during the procedure (eg: pneumothorax , pericarditis, infection, skin erosion, hematoma, lead dislodgment, and venous thrombosis). Treatment depends on the etiology. Erosion of the pacer through the skin, while rare, may requires device replacement and systemic antibiotics. Lead dislodgment generally occurs within 2- 3 days of device implantation and may be seen on chest radiography. If the affected lead is the one for the ventricle, severe heart rythms arrythmia can occure.

•failure to shock and ineffective cardioversion

•lead dislodgment, lead fracture

•arrythmias

Twiddler’s syndrome – Some patients will persistently disturb and manipulate the pacemaker generator, resulting in malfunction. A chest radiograph may reveal twisting or coiling or may show lead fracture, dislodgement, or migration. This situation will require surgical correction, with further patient education and counseling.

Pacemaker syndrome – pacemaker syndrome is a phenomenon in which a patient feels symptomatically worse after pacemaker placement and presents with progressively worsening symptoms of congestive heart failure (CHF).

•Pneumothorax, hemothorax, hemopneumothorax

•rare: cardiac perforation with or without pericardial effusion and tamponade (sometimes requiring urgent drainage), pulmonary embolism, tricuspide valve lesions

•deep venous thrombosis and edema in upper extremity

•infective endocarditis

•battery exhaustion

Before procedure

Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.

You will be asked to sign a consent form that gives permission to do the procedure.

In addition to a complete medical history, your doctor may perform a physical examination to ensure you are in good health before you undergo the procedure. You may also undergo blood tests and other diagnostic tests.

You will be asked to fast for eight hours before the procedure, generally after midnight.

If you are pregnant or suspect that you are pregnant, you should notify your health care provider.

Notify your doctor if you are sensitive to or are allergic to any medications, latex, iodine, tape, contrast dyes, and anesthetic agents (local or general).

Notify your doctor of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.

Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure. If you take Sintrom, the results of your INR test (a blood test to evaluate the blood clotting) must be within a suitable range before the implant procedure can be performed. You will likely need to stop taking anticoagulant medications (Warfarin) or antiagregant medications, including aspirin or plavix, a few days before the procedure.

Your doctor may also ask you to stop taking other medications, such as those that control your heart rate.

Do not stop taking any of your medications without first consulting with your healthcare provider. Ask your doctor which medications you should stop taking and when to stop taking them.

Based on your medical condition, your doctor may request other specific preparation.

A very important element is cardiac echography. In case of cardiac failure, a special echocardiography searching differents parameters (for asyncronism) is needed before your doctor can tell you what kind of device is proper for you ( if you need a biventricular device).

After procedure

This is a minimally-invasive procedure, so the recovery is usually quick. Most of the patients can leave the hospital the day after the procedure, unless the epicardial approach was used during the procedure ( in this case the hospitalization can be longer: 3-5 days). At home check out for fever, pain or alteration at the incision place.

In the hospital : you will be connected to monitors that will constantly display your electrocardiogram tracing, blood pressure, other pressure readings, breathing rate, and your oxygen level.

A chest X-ray will be done after the device implant procedure to check your lungs as well as the position of the device and lead(s). Also, your doctor will repeat the ecocardiogram.

At home : You’ll also review your home-going instructions, including incision care, activity guidelines and follow-up schedule. You should not move your arm above your shoulder. Take a pain reliever for soreness as recommended by your doctor. Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.

Long term follow-up include Holter EKG records, echocardiogram evaluations according to the follow-up schedule. You need to know that the device has a time-life between 3 and 6 years, so you need to complete the follow-up according to your doctor receommendations.

You will receive a ID card that tells you what type of device and leads you have, the device manufacturer, the date of the device implant and the doctor’s name who implanted the device.

Although technologic advances have greatly reduced the potential effects of EMI, patients should be advised to avoid strong electromagnetic fields because of potential interference with sensing circuitry. Examples of potential hazards include arc welders, large generators, and magnetic resonance imaging (MRI) magnets. Household appliances, microwave ovens, cell phones, and hand-held metal detectors (used for security screening) should not pose a serious threat.

A shock from an implantable cardioverter-defibrillator (ICD) is generally painful. Patients should be advised of this in advance. Although implantable cardioverter-defibrillators (ICDs) are extremely effective in terminating life-threatening arrhythmias, many patients require adjunctive therapy to reduce the frequency of arrhythmic events that require therapy. This generally consists of pharmacologic therapy, and, particularly in cases of failure of drug therapy, radiofrequency catheter ablation. Inappropriate shocks may be delivered for atrial fibrillation, sinus tachycardia, and other types of supraventricular tachycardia, prompting ICD reprogramming or adjunctive therapy.

Important!

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Within our centres of excellence, both the patient and his/her doctor can choose the interventional cardiologist from our reputable team. As soon as a procedure is performed, the patient will receive a written report and a CD containing recorded images of the intervention and also the ID card (that tells you what type of device and leads you have, the device manufacturer, the date of the device implant and the doctor’s name who implanted the device) and the doctor is informed about his/her patient’s health status.

DOCTORS
that perform the procedure

X
Sună Mesaj