Pacemaker and other Implantable Heart Devices
Types, Costs, Procedure, Benefits and Risks
Types of Cardiac Devices
What are implantable heart devices and when do doctors recommend them?
Implantable heart devices are electronic, battery-operated medical devices used to control the rhythm, support heart and circulation, or monitor rhythms. The devices include –
- Biventricular pacemakers or Cardiac Resynchronization Devices (CRDs)
- Implantable Cardioverter Defibrillators (ICDs)
- Left Ventricular Assist Devices (LVADs)
- Heart rhythm monitors or Implantable Cardiac Loop Recorders (CLRs)
Pacemakers: A pacemaker is an electronic device, to assist the heartbeat in a specific way. It has few insulated wires, battery and a circuit, programmed to regulate the electrical impulses in the heart. It is surgically placed by a cardiologist below the collarbone in the chest. Pacemakers may be implanted temporarily or permanently and may or may not be monitored by the doctor from the hospital.
Pacemakers may be of different types, depending on the area of the heart where the impulses are distributed.
- Single chamber pacemaker: Electrical impulses from the pacemaker are sent to the right ventricle of the
- Dual chamber pacemaker:Electrical impulses from the pacemaker are sent to the right ventricle and the right atrium of the heart.
Pacemaker implantation may be indicated in heart conditions, not limited to:
- Commonly used in Bradycardia (a slow heartbeat).
- Other arrhythmias – atrial fibrillation, ventricular tachycardia, & ventricular arrhythmia.
- Heart block
- Sick sinus syndrome
- Congestive heart failure
- Heart attack or cardiac arrest
Biventricular pacemakers or Cardiac Resynchronization Devices (CRDs): Biventricular pacemakers work similar to pacemakers but also send electrical impulses to the heart to resynchronize ventricular contractions (pumping of lower chambers of the heart). Also known as CRDs, they are used in patients with heart failure who do not respond to medicines. This pacemaker helps to bring coordination between atria and ventricles so they both contract in synchronized heart rhythm. The device and the benefits may be monitored by the doctor sitting at the hospital.
Implantable Cardioverter Defibrillators (ICDs): Implantable cardioverter defibrillators (ICDs) devices are used to restore heart rhythm and prevent cardiac death. It is helpful in patients with abnormal heart rhythm (arrhythmias) and who are at risk of recurrent, sustained ventricular tachycardia or ventricular fibrillation.
The ICD detects abnormal rhythm and automatically shocks the heart to restore regular heartbeat and blood circulation. Many ICDs come with an inbuilt pacemaker which normalizes slower heartbeats. The ICDs may be implanted in the chest wall below the collarbone or beneath the skin (subcutaneous internal cardioverter defibrillator).
Left Ventricular Assist Devices (LVADs): An LVAD is used to support the heart in maintaining effective blood circulation by assisting left ventricles, the lower chamber that pumps blood out to the body.
LVAD is used for patients who are awaiting a heart transplant, thus it is also known as “bridge to transplant”. This device assists blood pumping and prevents further deterioration of already-weakened heart thus sustain the life of patient till a heart is available for transplantation. It is also used in end-stage heart failure when heart transplantation is not an option and thus it is also called as “Destination therapy”.
Heart rhythm monitors or Implantable Cardiac Loop Recorders (CLRs): Implantable loop recorders are wireless cardiac monitors that continuously record heart rhythm for years, usually up to 3 years. Doctors recommend implanting loop recorders in patients who have a history of unexplained heart palpitations and fainting spells that go undetected by devices such as Holter monitors. ILRs provide data much like that received from an ECG or EKG. The device finds its utility also in patients with atrial fibrillation and/stroke of undermined cause. Cardiac loop recorders are available which might either be inserted in the chest or beneath the skin of the patient.
Risks and Benefits
What are the different implantation surgery and pacing options available?
Implantation surgery for pacemakers and ICDs:
A heart device is implanted beneath the clavicle or collarbone & bridge is formed from the device to the heart. The surgery takes about an hour or two under sedation and requires an overnight stay.
In most of the cases, the heart device is implanted in the chest wall beneath the collarbone and connected via leads to the heart. After 2 weeks from the day of surgery, the doctor checks the implantation site, confirms the working condition of the device, and looks for any arrhythmias experienced since then. The patient may then be scheduled for frequent, usually biannual doctor visits.
Subcutaneous devices, such as subcutaneous internal cardioverter defibrillator and cardiac loop recorders, are otherwise implanted under the skin beneath the collarbone (as for cardiac loop recorder) or at the side of the chest below the armpit (as for an internal cardioverter defibrillator).
The latest cardiac loop recorders are very small and can be injected under the skin. The procedure is done under local anesthesia and the patient may return home soon after. In this procedure, a small puncture is made in the skin to the left of the collarbone and the recorder is inserted via a small plastic applicator. The puncture is then sealed using solvable sutures.
Implantation surgery for LVAD:
LVAD is heart pump which is implanted just below the heart or the upper part of the abdomen. The one end of the device is connected to the left ventricle and the other end is connected to the aorta so, the device collects blood from the left ventricles and sends it to the aorta. A tube from the LVAD is brought out of the abdominal wall, through the skin, and connected to an external control device (portable options are available) and power source.
Temporary pacing: Temporary pacing may be performed either by an internal or external process. This method is opted only in reversible health conditions until a pacemaker is available for permanent pacing.
- Internal pacing: Transvenous pacing and Epicardial pacing
Epicardial pacing is used during surgeries.
Transvenous pacing is performed by placing a bridge (electric lead) through the vein. The bridge connects to the heart through venous access and is secured to the skin. The patient is evaluated for infections and heart conditions daily until the bridge is being used with an external pacemaker.
- External pacing: Percussive pacing or transcutaneous pacing
External pacing is performed either mechanically by percussive pacing or electrically by transcutaneous (electric pulses through the skin above chest) pacing. External pacing is usually not reliable and used only until internal pacing can be achieved.
How long do the pacemaker and heart devices last?
Pacemaker: The battery of the pacemaker may last for anything between 5 to 15 years. The pacemaker’s pulse generator is replaced once the battery wears off. At the time of replacement, sometimes the leads may be left as it is and replaced only at a later date. The replacement procedure is quicker and requires less time for recovery as compared to the implantation procedure.
ICD lasts for 5 to 10 years. When the battery is nearly out, the shock generator is replaced with the new one in a minor outpatient procedure.
LVADs last for at least 7 years, and the batteries last for 14 hours.
Cardiac Loop Recorders: A CIR lasts for up to 36 months (3 years) and needs to be replaced regularly. The device is removed in a procedure similar to implantation surgery through the original incision site.
What are the risks and benefits of implantation?
With advancements in medical technology, pacemakers are now considered as the gold standard treatment for many conditions that disrupt the heart’s electrophysiology.
- A patient may get rid of disturbing symptoms of an abnormal heart rate
- Modern day pacemakers automatically adjust the patient’s heart rate to match the extent of their physical activity thus helping them resume their normal lifestyle
Pacemaker implantation is a surgical procedure generally carried out under local anesthesia. It carries with it the risks of a surgery like, but not limited to:
- Abnormal bleeding or swelling at the surgical site
- Allergic reaction to the dye or anesthesia
- Collapsed lung
- Damage to the heart or its neighboring structures like blood vessels or lungs
- Infection at the site of implantation
- Life-threatening risks of the procedure (extremely rare)
What are the side effects or complications of the implantable heart devices?
Some complications may arise due to the technique of placement of the device, which include:
- Abnormal pulse generation from the pacemaker
- Air embolism
- Dislodgement of the lead
- Piercing of the device through the skin
- Venous thrombosis
Surgery and Procedure
How is recovery after heart device implantation surgery like?
The patient may stay in hospital for a day or two after surgery. The device is tested before the patient is discharged. The patient may be prescribed pain medicines to manage pain in incision area that may last for a few days or weeks. The healthcare team shall advice on:
- Care of the incision site
- Identifying signs of infection
- Follow up appointments
- Emergency advice
What are the precautions needed with the pacemakers and other implanted heart devices?
Some precautions advised by cardiologists are enlisted below:
- Lifting objects more than 5 kg
- Raising the affected arm above the shoulder level
- Pulling and pushing heavy objects
- Games like tennis and golf for around six weeks after the implantation
- Using mobile phone from the side of placement and placing in the pocket on chest
- Standing or sitting close to the security systems and metal detectors at airports, hotels, malls etc.
- Proximity to equipment with magnets or with electromagnetic fields like electric generators and industrial welders.
Inform your doctors if you are advised any medical procedures like MRI scan, electro-cauterization procedure for any surgery or shock-wave lithotripsy for treating kidney stones as it can interfere with the pulse generation.
What factors should be considered while choosing a hospital for heart device implantation surgery?
For heart device implantation surgery, it is important to ensure that the hospital has the standard infrastructure and trained team to support the pre-operative and post-operative needs of the treatment.
The most important consideration while choosing a hospital for heart device implantation surgery is the cardiothoracic surgeon and his team. The success of surgery depends on the –
- Expertise and skills of the surgeon: Specializedtraining, number of surgeries performed and success rate are indicative of the skill set of your cardiothoracic
- Advanced operation theatre facilities including provisions to monitor and control infections.
- Post-operative care: Trained team of cardiothoracic surgeons, anesthetist, nursing and paramedical staff to ensure a pain-free postoperative recovery and aftercare.
What factors govern the cost of heart device implantation surgery?
Although pacemaker implantation is generally carried out under local anesthesia, factors like patient’s medical condition that may warrant an extended stay in the hospital, thus impacting the cost of the procedure in addition to the cost of the device, investigations and medications as required.
The cost of surgery depends on many factors, namely:
- Cost of implantable heart device – pacemaker, CRT, ICD, LVAD etc.
- Surgicalconsumables, equipment required
- Expertise of the cardiothoracic surgeon and team
- Underlying medical condition of the patient, which can affect the hospital stay, additional tests and medicine requirement
To know more about pacemaker implantation, you can request a callback and our experts will call you and answer all your queries.
Related blogs you may like to read:
- Implantable Medical Devices. Available at:http://www.heart.org/HEARTORG/Conditions/HeartAttack/TreatmentofaHeartAttack/Implantable-Medical-Devices_UCM_303940_Article.jsp#.Wu1gW6SFOM8 Accessed on 05th May
- Johns Hopkins Medicine. Pacemaker Insertion. Available at:https://www.hopkinsmedicine.org/healthlibrary/test_procedures/cardiovascular/pacemaker_insertion_92,P07980 Accessed on 19th Feb 2018.
- Pacemaker implantation. Available at:https://www.nhs.uk/conditions/pacemaker-implantation/. Accessed on 19th Feb 2018.
- Pacemaker implantation. Available at:https://www.nhs.uk/conditions/pacemaker-implantation/what-happens/ Accessed on 19th Feb 2018.
- American Heart Association. Cardiac Pacemakers From the Patient’s Perspective. Available at: http://circ.ahajournals.org/content/105/18/2136Accessed on 19th Feb 2018.