Dr. Paul Khairy, MD, FRCP, Cardiologist, talks about how pacemakers work and how they are implanted to treat patients with irregular heart rates.

Dr. Graham Wong, Cardiologist, MD, MPH, FRCPC, FACC, discusses pacemakers.

Dr. Bernice Tsang, MD, FRCPC, Electrophysiologist, talks about the what to expect when you come in for a pacemaker or defibrillator insertion. Southlake Regional Health Centre

Depending on your condition, you might have one of the following types of pacemakers.

• Single chamber pacemaker. This type usually carries electrical impulses to the right ventricle of your heart.
• Dual chamber pacemaker. This type carries electrical impulses to the right ventricle and the right atrium of your heart to help control the timing of contractions between the two chambers.
• Biventricular pacemaker. Biventricular pacing, also called cardiac resynchronization therapy, is for people with heart failure with abnormal electrical systems. This type of pacemaker stimulates the lower chambers of the heart (the right and left ventricles) to make the heart beat more efficiently.

There are two different kinds of pacemakers. Pacemakers that sit under the skin and have one, or up to three wires that go through a vein into the chambers of the heart. And there are pacemakers that have no wires, that go up through the groin and are tethered into the heart tissue but have no leads.

Leadless pacemakers are placed through a tube that’s placed in the groin under local anesthetic. There is a catheter much like a fishing rod that is placed through that tube. The leadless pacemaker is at the end of that catheter, and there are tines at the end of the pacemaker.

The tines then attach to the tissue of the heart. The pacemaker is then set free, much like a fish on a fishing wire. The wires are let out, the pacemaker is checked and then the fishing line is cut to let the pacemaker free. Then the catheter is withdrawn and the tube is taken out.

This is also a day procedure. Leadless pacemakers, unlike pacemakers that are placed with wires in the heart, have potential benefits. This may be a lower risk of infection, there is no incision or sutures.

Lynda Gallagher, BSc., RN, CCN(C), CCDS, Nurse, talks about pacemakers and defibrillators, how they are inserted and their functionality. Southlake Regional Health Centre

There are two different kinds of devices: pacemakers and defibrillators. Pacemakers are used to treat slow rhythm problems, and defibrillators are used to treat fast rhythm problems coming from the bottom part of the heart.

Devices are placed under conscious sedation. You do not need a general anesthetic for the procedure. The procedure takes anywhere between 10 minutes for a battery replacement and about 20 minutes for a new device.

Pacemakers and defibrillators are implanted under the skin under local anesthetic. You’re given a mild sedative to help you relax and a pocket is made under the skin, the wires are then placed into the vein into the heart. The wires are then connected up to the device and the incision is closed with dissolvable sutures.

An implantable defibrillator or pacemaker is considered day surgery. You come in through the day in the morning and are discharged by the afternoon. There are certain risks, and possible contraindications and indications to having your defibrillator and/or pacemaker. The risks include infection and bleeding, risk of puncture to the heart or puncture to the lung. There’s a small risk that the wires may come retracted from the heart, for which we’d have to go back in and plug it into place. And as long as you have the device there’s a risk of infection.

Patients who have implanted devices are restricted from driving for about a week. Thereafter, they can return to normal work. There is a small restriction with devices that have had leads inside the vein, in that you’re not to raise your arm for a couple of weeks, to minimize the risk that the wires come retracted from the heart.

Patients who have implanted devices, whether it’s a pacemaker or defibrillator, generally lead very normal lives. There’s no restrictions on using microwaves or cell phones, and patients are able to travel. Pacemakers will help patients feel much more energetic, will improve their exercise capacity and generally improve the quality of life.

It’s normal to feel stressed and anxious about your procedure. We’ll be able to deal with that with medications before the procedure happens. We are certainly here to answer any questions you might have before the procedure and as well as after the procedure, and we are available to you at any time through a phone call or a follow-up visit.

Southlake Regional Health Centre

Presenter: Dr. Bernice Tsang, Electrophysiologist, Newmarket, ON

Local Practitioners: Electrophysiologist

A pacemaker is a sophisticated medical device that is typically implanted under the skin in the chest or abdomen to manage a slow heart rate. The pacemaker system consists of two main components. The first is the pacemaker generator, the pulse generator. It houses the battery and the electronics that are required to analyze information and control the impulses that are sent to the heart to manage the heart rate.

The second component consists of one or more or these electrical wires that we call pacemaker leads, and these wires are connected to the pulse generator, and they carry electrical impulses to and from the heart. Some patients require one, two or three pacemaker leads depending on the clinical situation. Some patients need a pacemaker to replace the normal electrical conduction system of the heart that is not functioning properly.

When the heart beats too slowly or there are excessive pauses, it can give rise to symptoms such as fatigue, shortness of breath or dizziness. More serious symptoms include a loss of consciousness, injury and occasionally sudden death. Now some patients with electrical conduction problems that also have heart failure require a special type of pacemaker that allows the two sides of the heart to beat in sync – a biventricular pacemaker. So this allows the two sides of the heart to beat in a more coordinated and efficient manner.

Pacemakers are typically implanted in a specialized operating room for arrhythmias by  a cardiologist . An entire team is present to ensure that the person is comfortable and well-sedated during the intervention, and a local anesthetic is injected at the surgical site to numb the area. Typically a three- to four-centimetre incision is made in the pectoral region, and then a small pocket is created under the skin to house the pulse generator. And then one or more of the pacemaker leads are then inserted through a vein near the collarbone and into the heart. The leads are then connected to the pulse generator, which is placed in the surgical pocket that was created, and the surgical incision is closed with absorbable sutures.

Pacemaker surgeries are considered a low-risk intervention. Nevertheless, as with any intervention complications can occur. The overall rate of complications is less than three percent. This includes allergic reactions to anesthesia, to antibiotics, bleeding at the surgical site, a collapsed lung due to a needle puncture when inserting the pacemaker leads, a punctured heart and infections that could occur weeks after the procedure.

After pacemaker surgery, patients typically will leave the hospital the day after. And then over the next month or so they should avoid vigorous exercises, especially those involving the arms, as well as heavy lifting – so no more than five to ten kilograms. Now after patients have fully recovered from the surgery they could resume their normal activities, with few restrictions such as avoiding full contact sports.

Now modern pacemakers are much less sensitive to electromagnetic interference than older models, but nevertheless electromagnetic interference can occur. Home appliances are not generally problematic, with the exception of induction cooktops that could interfere with certain types of pacemakers.

From a work perspective, patients should avoid industrial welding and exposure to high intensity electromagnetic fields. So if the person has a concern about potential electromagnetic interference in the workplace, it should be discussed with the medical team. Sometimes a more detailed evaluation is required to ensure safety.

After the pacemaker is implanted, patients will be given an appointment four to eight weeks later at a specialized pacemaker clinic. There we check the incision site to ensure that it looks good, and we verify all the components of the pacemaker to ensure that it is functioning properly. Patients will be relieved to know that we do not need to open up the surgical site to take out a pacemaker in order to check it. It is done using specialized programmers wirelessly, and patients do not need to undress for this procedure.

Now several different models of pacemakers have the capacity to be followed at a distance. So if a patient has this type of pacemaker and is willing, we will equip them with a small monitor free of charge that we recommend placing at the bedside. And this monitor interrogates the pacemaker at regular intervals and it sends that information to us. So it allows us to detect problems early, and it avoids the need for regular in-person visits.

One of the elements that we follow during these regular pacemaker checkups is the battery life. On average pacemaker batteries last about 10 years or more, and having these regular pacemaker checks allows us to ensure that we change the pulse generator before the battery becomes depleted. This also has the advantage of not having a pacemaker last a lifetime, because a pacemaker is a sophisticated computer, and it benefits from upgrades in technology. So changing a device every 10 years or so with the new features that are developed could actually be an advantage.

If you have any fears or anxieties or any other questions related to your pacemaker, contact your doctor, cardiologist or pacemaker clinic.

Presenter: Dr. Paul Khairy, Cardiologist, Montreal, QC

Patricia Edwards, Regional Cardiac Program Social Worker, Southlake Hospital, talks about discharge options and care for cardiac patients after surgery.

Bertrand Bolek, MN, Nurse Practitioner – Adult, talks about how heart failure patients can prevent symptoms by restricting daily fluid intake. Southlake Regional Health Centre

Bertrand Bolek, MN, Nurse Practitioner – Adult, talks about why and how heart patients can restrict their salt intake.