Pacemaker

this is dealt about the pacemaker temporary and permanent its aim and basic indication for pacemaker breif history of pacemaker development its design and detailed indication of both temporary and permanent pacemaker then method of pacing which should be based on the patient ECG its parts and procedure and complication

1. PACEMAKER

2. INTRODUCTION: Many condition can affect the ability of the heart conduction system to function normally, creating circumstances that warrant pacing. When the S.A. node is seriously damaged and is unable to act as the pacemaker of the heart or when the impulses from the S.A. node and the atria are not adequately transmitted through the A.V. junction to the ventricles (Heart Block). The artificial pacemaker controls the heart beat by means of electrical stimulation of ventricles.

3. A cardiac pacemaker is an electronic device that delivers direct electricial stimulation the myocardium to depolarize, intiating a mechanical contraction . The pace maker initiates and maintain the heart rates when the heart’s natural pacemaker is unable to do so . Pacemaker can be used to correct bradycardias , tachycardias , sick sinus syndrome and second – and third –degree heart block, and for prophylaxis .Pacing may be accomplished through a permanent implantable system, a temporary system with an external pulse generator and percutaneous threaded leads, or a transcutaneous external system with electrode pads placed over the chest.

4. DEFINITION A pacemaker is an electronic device that provides electronic stimuli that provides an artificial SA node and/or parkinje system. The artificial cardiac pacemaker is an electronic device used to pace the heart when the normal conduction pathway is damaged or diseased.

5. AIMS To control cardiac rate and rhythm when the natural pacemaker is destructive or destroyed To initiate cardiac activity in ventricular standstill.

6. INDICATION To treat partial or complete heart block with Stokes-Adams attacks that do not respond to drug therapy. To correct drug resistant bradycardias when accompanied by insufficient cardiac output or congestive heart failure. To permit administration of high dose of suppressive drugs for the prevention of recurrent tachyarrhythmias

7. 4. To treat ventricular tachycardia (resistant to conventional therapeutic measures) and cardiac arrest 5. As a prophylaxis following cardiac surgery.

8. HISTORY OF PERMANENT PACEMAKER INCERTION In 1958, Arne Larsson (1915–2001) became the first to receive an implantable pacemaker. He had a total of 26 devices during his life and campaigned for other patients needing pacemakers.

9. Origin In 1889, John Alexander MacWilliam reported in the British Medical Journal (BMJ) of his experiments in which application of an electrical impulse to the human heart in asystole caused a ventricular contraction and that a heart rhythm of 60–70 beats per minute could be evoked by impulses applied at spacings equal to 60–70/minute

10. In 1926, Dr Mark C Lidwill of the Royal Prince Alfred Hospital of Sydney, supported by physicist Edgar H. Booth of the University of Sydney , devised a portable apparatus which "plugged into a lighting point" and in which "One pole was applied to a skin pad soaked in strong salt solution" while the other pole "consisted of a needle insulated except at its point, and was plunged into the appropriate cardiac chamber".

11. " The pacemaker rate was variable from about 80 to 120 pulses per minute, and likewise the voltage variable from 1.5 to 120 volts". In 1928, the apparatus was used to revive a stillborn infant at Crown Street Women's Hospital, Sydney whose heart continued "to beat on its own accord", "at the end of 10 minutes" of stimulation.

12. In 1932, American physiologist Albert Hyman, with the help of his brother, described an electro-mechanical instrument of his own, powered by a spring-wound hand-cranked motor. Hyman himself referred to his invention as an "artificial pacemaker", the term. continuing in use to this day

13. PACEMAKER DESIGN A pacemaker provides an external energy source for impulse formation and delivery. Whereas numerous pacemaker models are available, the basic pacing circuit consist of Power source (battery-powdered pulse generator) b. One or more conducting leads (pacing leads) c. Electrodes system

14. TYPES OF PACEMAKERS

15. EXTERNAL PACEMAKER: The pulse generator remains outside the body and the electrical stimulation is conveyed to the heart through the pacing catheter. The external pacemakers are always temporary pacemakers. There are three types of temporary pacemaker: transvenous, epicardial and transcutaneous

16. Transvenous pacemaker : It consist of a lead or leads that are threatened trsansvenously to the right atrium and/or right ventricles and attached to the external power source

17. b. Epicardial pacing: It is achieved by attaching an atrial and ventricular pacing lead to the epicardium during heart surgery. The leads are passed through the chest wall and attached to the external power source. Epicardial pacing leads are placed prophylactically should any bradydysrhythmias or tachydysrhythmias occur post operatively.

18. c. Transcutaneous pacemaker: It is used to provide adequate heart rate and rhythm to the patient in an emergency situation. Placement of the transcutaneous pacemaker is an non-invasive procedure that is used temporarily until a transvenous pacemaker can be inserted or until more definitive therapy is available.

19. Before initiating TCP therapy, it is important to tell the patient what to expect. The uncomfortable muscle contractions that the pacemaker creates when the current passes through the chest wall should be explained. The patient should be reassured that the therapy is temporary and that every effort will be made to replace the TCP with a transvenous pacemaker as soon as possible. Whenever possible, analgesia and/or sedation should be provided.

20. INDICATION FOR TEMPORARY PACEMAKER Maintenance of adequate heart rate and rhythm during special circumstances such as surgery and postoperative recover, cardiac catheterization or coronary angioplasty, during drug therapy that may cause bradycardia, and before implantation of a permanent pacemaker As prophylaxis after open heart surgery Acute anterior MI with second-degree or third degree block AV block or bundle branch block

21. Acute inferior MI with symptomatic bradycardia and AV block Electrophysiologic studies to evaluate patient with bradydysrhythmias and tachydysrhythmias .

22. Contraindication of temporary pacemaker: These are all relative. Sometimes, one may wish to commence pacing in the face of these contraindications, because the benefits outweigh the risk. Frequently, of course, external pacing is still an option. Excessive risk of bleeding due to vascular access Ongoing bacteraemia   Hemodynamically stable bradycardia Large areas of  right ventricular infarction Intracardiac thrombus: One might dislodge this either by stimulating the chamber, or by the very act of inserting transvenous pacing lines.

23. INTERNAL PACEMAKER: The pulse generator is implanted in the subcutaneous tissues and the electrical stimulation is passed to the heart through the pacing catheters. The internal pacemakers are always permanent pacemakers

24. The permanent pacemaker power source is implanted subcutaneously, usually over the pectoral muscle on the patient’s non-dominant side. It is attached to pacing leads, which are threaded transvenously to the right atrium and one or both ventricles. The specialized type of cardiac pacing has been developed for the management of heart failure. More than 50% of heart failure patients have intraventricular conduction delays causing abnormal ventricular activation and contraction and subsequent dyssynchrony between the right and left ventricles. This can result in reduced systolic function, pump insufficiency, and worsened heart failure. Cardiac resynchronization therapy is a pacing technique that resynchronizes the cardiac cycle by pacing both ventricles, thus promoting improvement in ventricular function. Several devices are available that have combined cardiac resynchronizes therapy with an implanted cardioverter -defibrillator for maximum therapy.

25. INDICATION FOR PERMANENT PACEMAKER Acquired AV block Second degree AV block Third degree AV block Bundle branch block

26. Cardiomyopathy Dilated Hypertonic Heart failure Hypersensitive carotid sinus syndrome SA node dysfunction Tachydysrhythmias

27. Contraindication of permanent pacemaker : Biofeedback : Dermatological condition( e.g eczema,dermatitis ) Allergy to the electrode or contact material( tape,gel ) Patient who are unable to understand or respond to the instructions of the therapist.

28. Cryotherapy : General ,advanced cardiovascular diseases. Local area of impaired peripherial circulation. Extensive scar tissues- poor blood supply may lead to ice burn.

29. Interferential therapy: Patient who do not comprehend the physiotherapist’s instruction or unable to co –operate treated. Patient who are taking anti coagulation therapy or have a history of pulmonary embolism or deep vein thrombosis should not treated with vaccum electrode application.

30. Laser therapy: Active or suspected carcinoma. Direct irradiation of the eyes. Increased sensitivity to light.

31. Infra Red : Area with poor or deficient skin sentation . Generalised advanced cardiovascular disease. Extensive scar tissue.

32. METHOD OF PACING An ECG in a person with an atrial pacemaker. Note the circle around one of the sharp electrical spike in the position where one would expect the P wave. An ECG of a person with a dual chamber pacemaker

33. Percussive pacing Ventricular contraction is achieved by means of a thin wire electrode inserted directly into the myocardium by way of a needle introduced through the chest wall. Another electrode is placed externally on the chest wall to complete the circuit. The major advantage of this method is the rapidity with which the pacing can be started. Therefore, this technique is of much use in time of emergency, e.g. when ventricular asystole develops unexpectedly.

34. Percussive pacing, also known as transthoracic mechanical pacing, is the use of the closed fist, usually on the left lower edge of the sternum over the right ventricle in the vena cava , striking from a distance of 20 – 30 cm to induce a ventricular beat (the British Journal of Anaesthesia suggests this must be done to raise the ventricular pressure to 10–15 mmHg to induce electrical activity ). This is an old procedure used only as a life saving means until an electrical pacemaker is brought to the patient

35. Transcutaneous pacing Transcutaneous pacing (TCP), also called external pacing, is recommended for the initial stabilization of hemodynamically significant bradycardias of all types. The procedure is performed by placing two pacing pads on the patient's chest, either in the anterior/lateral position or the anterior/posterior position.

36. The rescuer selects the pacing rate, and gradually increases the pacing current (measured in mA) until electrical capture (characterized by a wide QRS complex with a tall, broad T wave on the ECG) is achieved, with a corresponding pulse. Pacing artifact on the ECG and severe muscle twitching may make this determination difficult. External pacing should not be relied upon for an extended period of time. It is an emergency procedure that acts as a bridge until transvenous pacing or other therapies can be applied.

37. Epicardial pacing (temporary ) ECG rhythm strip of a threshold determination in a patient with a temporary (epicardial) ventricular pacemaker. The epicardial pacemaker leads were placed after the patient collapsed during aortic valve surgery. In the first half of the tracing, pacemaker stimuli at 60 beats per minute result in a wide QRS complex with a right bundle branch block pattern.

38. Progressively weaker pacing stimuli are administered, which results in asystole in the second half of the tracing. At the end of the tracing, distortion results from muscle contractions due to a (short) hypoxic seizure. Because decreased pacemaker stimuli do not result in a ventricular escape rhythm, the patient can be said to be pacemaker-dependent and needs a definitive pacemaker.

39. Temporary epicardial pacing is used during open heart surgery should the surgical procedure create atrio -ventricular block. The electrodes are placed in contact with the outer wall of the ventricle ( epicardium ) to maintain satisfactory cardiac output until a temporary transvenous electrode has been inserted.

40. Transvenous pacing ( temporary) The heart can be effectively stimulated from a small electrode placed within the right ventricle. This pacing electrode is introduced into a superficial vein and then advanced through the vena cava into the right atrium until it is lodged against the endocardial surface of the right ventricle. The electrical stimulus is delivered from a small battery-powdered pulse generator. This technique is used routinely in most of the coronary care units.

41. Transvenous pacing, when used for temporary pacing, is an alternative to transcutaneous pacing. A pacemaker wire is placed into a vein, under sterile conditions, and then passed into either the right atrium or right ventricle. The pacing wire is then connected to an external pacemaker outside the body. Transvenous pacing is often used as a bridge to permanent pacemaker placement. It can be kept in place until a permanent pacemaker is implanted or until there is no longer a need for a pacemaker and then it is removed.

42. Right atrial and right ventricular leads as visualized under x-ray during a pacemaker implant procedure. The atrial lead is the curved one making a U shape in the upper left part of the figure.

43. Subclavicular pacing Permanent pacing with an implantable pacemaker involves transvenous placement of one or more pacing electrodes within a chamber or chambers of the heart, while the pacemaker is implanted inside the skin under the clavicle. The procedure is performed by incision of a suitable vein into which the electrode lead is inserted and passed along the vein, through the valve of the heart, until positioned in the chamber.

44. The procedure is facilitated by fluoroscopy which enables the physician to view the passage of the electrode lead. After satisfactory lodgement of the electrode is confirmed, the opposite end of the electrode lead is connected to the pacemaker generator. There are three basic types of permanent pacemakers, classified according to the number of chambers involved and their basic operating mechanism

45. Single-chamber pacemaker. : In this type, only one pacing lead is placed into a chamber of the heart, either the atrium or the ventricle Dual-chamber pacemaker . : Here, wires are placed in two chambers of the heart. One lead paces the atrium and one paces the ventricle. This type more closely resembles the natural pacing of the heart by assisting the heart in coordinating the function between the atria and ventricles.

46. Rate-responsive pacemaker . : This pacemaker has sensors that detect changes in the patient's physical activity and automatically adjust the pacing rate to fulfill the body's metabolic needs.

47. Biventricular pacing : Three leads can be seen in this example of a cardiac resynchronization device: a right atrial lead, a right ventricular lead, and a coronary sinus lead. The coronary sinus lead wraps around the outside of the left ventricle, enabling pacing of the left ventricle.

48. Note that the right ventricular lead in this case has to thickened aspects that represent conduction coils and that the generator is larger than typical pacemaker generators, demonstrating that this device is both a pacemaker and a cardioverter -defibrillator, capable of delivering electrical shocks for dangerously fast abnormal ventricular rhythm

49. Cardiac resynchronization therapy (CRT) is used for people with heart failure in whom the left and right ventricles do not contract simultaneously (ventricular dyssynchrony ), which occurs in approximately 25–50% of heart failure patients. To achieve CRT, a biventricular pacemaker (BVP) is used, which can pace both the septal and lateral walls of the left ventricle. By pacing both sides of the left ventricle, the pacemaker can resynchronize the ventricular contractions.

50. CRT devices have at least two leads, one passing through the vena cava and the right atrium into the right ventricle to stimulate the septum, and another passing through the vena cava and the right atrium and inserted through the coronary sinus to pace the epicardial wall of the left ventricle. Often, for patients in normal sinus rhythm, there is also a lead in the right atrium to facilitate synchrony with the atrial contraction. Thus, timing between the atrial and ventricular contractions, as well as between the septal and lateral walls of the left ventricle can be adjusted to achieve optimal cardiac function.

51. CRT devices have been shown to reduce mortality and improve quality of life in patients with heart failure symptoms; a LV ejection fraction less than or equal to 35% and QRS duration on EKG of 120 ms or greater.

52. PACING MODES Fixed rate pacing (set-rate type): The pacemaker delivers an electrical impulse at a pre-determined rate to stimulate the myocardium. Whether the heart requires a pacing stimulus or not, the pulse generator sends a impulses at a regular and constant rate. The instrument disregards the existing ventricular contraction of the heart. Thus there is a competition between the rate set by the pacemaker and the spontaneous rate of the patient’s heart. Pacing stimuli may fall on the vulnerable period of the T wave (R and T phenomenon) producing ventricular tachycardia and ventricular fibrillation. This may turn to be fatal for a patient. This mode of pacing is therefore, not used these days.

53. Demand pacing (stand-by): The demand pacemaker can detect the patient’s own heart activity and fire only when spontaneous ventricular activity is delayed by more than the ‘escape interval’. When the ventricular contraction occur spontaneously at the excepted time, the demand pacemaker is inhibited and no stimulus is produced. Thus the competition between the pacemaker and the patients own cardiac rhythm is avoided. This pacemaker may be set to operate at any chosen rate.

54. Parts of a cardiac pacemaker The main parts of an artificial cardiac pacemaker comprise a pulse generator and pacing catheter. The parts of the cardiac pacemaker very according to its type and make. However, certain feature are common to all models.

55. Output : This determines the mili -amperes of current delivered to the heart to stimulate the myocardium. The usual setting is 3-5 milli -amperes. It may be increased or decreased as desired . Rate : This setting determines the heart rate and the escape interval for the pacemaker in the demand mode. ‘escape interval’ is the time limit set at which the pacemaker will fire if no ventricular contraction occurs within that period.

56. Sensitivity : when the indicator is turned to asynchronous, the pacemaker will function in the fixed pacing mode. When set on demand, spontaneous depolarization of ventricles will be sensed and the pacing impulse will be inhibited suitably . Sense pace : This control indicates whether the pacemaker is functioning properly or not. Whenever the pacemaker senses ventricular depolarization, it is indicated by the flashing of a light or by deflection of a needle indicator.

57. On-off switch : this is used to turn the pacemaker on or off. It locks to prevent accidental turn off. Connector terminals: the pacing catheter terminals are attached here after the electrodes are implanted in the heart

58. Catheter electrodes: There are two basic type of electrodes; one with a single electrode incorporated in the tip of the catheter (unipolar electrode) and the other with two electrode about 1 cm apart from the distal end of the catheter (bipolar electrode). In order to stimulate the heart, the electrical impulse from the pulse generator must flow between two poles (electrode) to create an electric circuit . Handles : These can be used to strap the pacemaker to the patient’s body.

59. PROCEDURE OF PERMANENT PACEMAKER INSERTION Pacemaker /ICD insertion is done in the cardiac catherization laboratory or the electrophysiology laboratory .The patient is awake during the procedure although local anesthesia is given over the to help the patient incision site and generally sedation is given to help the patient relax during the procedure .A night or two of hospitalization may be recommended so that the functioning of the implanted devices may be observed

60. Show here is a chest x-ray. The large wide space in the middle is the heart. The dark spaces on either side are lungs. The small objects in the upper corner is an implanted pacemaker .A small incision is made just under the collarbone. The pacemaker/ICD leads is inserted into the heart through a blood vessels which runs under the collar bone . once the lead is in placed , it is tested to make sure it is in the right place and is functional .The lead then attached to the generator which is placed just under the skin through the incision made earlier .Once the procedure has been completed the patient goes through a recovery period of several hours.

61. There are certain instructions related to having an implanted permanent pacemaker or ICD .For e.g After the patient receive pacemaker or ICD patient will receive an identification card from the manufacturer that include information about patient your specific model of pacemaker and the serial number as well as how the device works .Patients should carry this card with themself at all times .So that the information is always available to any health care professional.

62. COMPLICATION OF PERMANENT PACEMAKER Local infection : At the entry site of the leads for temporary pacing, or at the subcutaneous site for permanent generator placement. Prophylactic antibiotics and antibiotic irrigation of the subcutaneous pocket prior to generator placement has decreased the rates of infection to less than 2 %. Pneumothorax : However , the current procedure and use of safe sheaths reduce this risk.

63. Bleeding and hematoma: At the lead entry sites for temporary pacing or at the subcutaneous sites for temporary pacing or at the subcutaneous sites for permanent generator placement. This usually can be managed with cold compresses and discontinuation of antiplatelet and antithrombotic medications. Hemothorax : It occur from the puncture of the subclavian vein or internal mammary artery.

64. Ventricular ectopy and tachycardia: It occur from the ventricular wall by the endocardial electrode.   Twiddler syndrome : May occur when the patient manipulates the generator causing lead dislodegement or fracture of the head.   Cardiac perforation : Resulting in pericardial effusion and rarely cardiac temponade which may occur at the time of implatantion or month later.

65. COMPLICATION OF TEMPORARY PACEMAKER: Failure to pace, eg . dislodged leads Vascular access complications, eg . hematoma, pneumothorax etc. Cardiac chamber access problems, eg . knotting in the chamber, or damage to the tricuspid valve

66. Cardiac chamber damage and potential for cardiac tamponade Lead thrombosis and pulmonary embolism Lead infection and infective endocarditis Arrhythmias, eg . VF, VT (due to the leads irritating the tissue) "Endless loop" reentrant tachycardia Stimulation of the diaphragm and interference with ventilation

67. Care of a patient with a pacemaker Immobilize : Immobilize the extremity where transvenous catheter is inserted through a superficial vein. Guard against any tension being placed on the pacing catheter in order to prevent displacement of the pacing catheter in order to prevent displacement of the catheter within the ventricle.

68. Monitor heart rate and rhythm: a paced beat is immediately preceded by a pacer spike on the ECG tracing. The QRS complex of the paced beat is wide and bizarre and resembles a premature ventricular contraction, because the paced beat is initiated in the right ventricle (ectopic) Characteristics: The QRS complex induced by the pacemaker is normal or bizarre in shape and widened; it is immediately preceded by a narrow deflection known as pacemaker spike.

69. Promote environment safety : check all the equipment in the patient’s room for proper grounding especially when an externally powered pacemaker is used. Make sure that the terminals of the electrode wires are properly covered. Any inadvertently passing through the electrode can cause ventricular fibrillation in the patient. Vital signs: check the vital signs and level of consciousness very frequently for the first few hours, then every hour for the next 24 to 48 hours.

70. Peripheral distal : check the peripheral pulses distal to the insertion site for signs of thrombosis, adequate circulation etc. Prevent infection and thrombophlebitis: Prevent infection and thrombophlebitis at the site of transvenous catheter. Change the dressings and apply antibiotic ointment at least once in 24 hours or as necessary. Check the insertion site for signs of bleeding, infection, swelling, redness, exudate etc.

71. Patient with temporary pacemaker: When moving a patient with temporary pacemaker, elevate the affected extremity to ensure adequate circulation (but never above the head). Do not move the patient by pulling at his affected axilla. If all vital signs are satisfactory, after a day or two, allow the patient to move out of the bed.

72. Provide emotional support: give full explanation of the function and use of pacemaker. Explain that the patient will not feel the electrical stimulation of the heart and will not be electrocuted. Teach how to take the pulse so that they can continue to record his pulse rate once they discharged from the hospital

73. Patient with permanent pacemaker : the patient with permanent pacemaker implanted in the chest. At the time of discharge, the patient should be advised to Take the pulse for one full minute. This is best done early in the morning before he gets out of the bed. The patient should make sure that the preset rate remain constant. Restrict the strenuous activities and to take frequent rest periods at home and at work.

74. Carry identification card along with them wherever they goes. This should have the information about the pacemaker, such as, the type of pacemaker implanted, date of insertion, pacing rate, doctor name and address etc. Avoid long distance travels specially when the battery is weak Avoid exposure to electromagnetic fields. The diathermy and electrosurgical procedures are also to be avoided

75. Avoid contact with faulty electrical equipment especially, while approaching it if they feels a small shock or experiences a sudden change in heart rate. Report any unusual findings such as an increase or decrease in pulse rate by 5 or more beats from the baseline records, constant hiccough, pain, swelling and discharge from the site of implant, dizziness, vertigo, shortness of breath, unwarranted fatigue etc. Follows the instruction strictly regarding medication, diet and follow up. They should seek medical advice atleast once in three months. Get the battery changed before it is completely depleted of its power. Lithium battery will last for 3 to 15 years and nuclear battery from 20 to 40 years.

76. PATIENT EDUCATION AND HEALTH MAINTENANCE Activity: Reassure patient the normal activities will be able to be resumed . Explain to the patient that takes about 2 month to develop full ROM of arm (fibrosis occur around the lead and stabilizer it in heart ).

77. Specific instruction include the following : Instruct patient not to lift items over 3 Ib (1.4 kg) or perform difficult arm maneuvers. Tell the patient to avoid activities that involves rough contact around pacemaker sites. Caution patient not to fire a refile with it resting over pacemaker implant. d)Instruct the patient do not rub or massage around the pacemaker site

78. Pacemaker failure: Teach patient to check own pulse rate daily for 1 full minute and keep a chart for physician visit .This pulse check should not be done at rest . Teach the patient to : Immediately report slowing of pulse lower than set rate or greater than 100. Report signs and symptoms of dizziness, fainting, palpation , prolonged hiccups, and chest pain to health care provider immediately. These signs are indicative of pacemaker failure Take pulse while these feeling are being experienced.

79. Electromagnetic interference: Advice patient that improvememt in pacemaker design have reduced problems of electromechanical interference( EMI) Caution patient that EMI could interference with pacemaker function. Inappropriate inhibition or triggering of pacemaker stimulation causing light – syncope or death. Atrial oversensing may cause inappropriate pacemaker accelerate and can cause palpitation ,hypotension or angina in patient.

80. c) Rapid pacing resulting in ventricular fibrillation. Explain the high energy radiation ,linear power amplifers antenas , industrial arc welder , electrocautery equipment, TENS , unshielded motors , MRI equipment found in facilities and junkyards may affect pacemaker function.

81. Care of pacemaker sites: Advice patient to wear loose –fitting clothing around the area of pacemaker implantation until it has healed. Watch for signs and symptoms of infection around generator and leads- fever, heat, pain ,and skin breakdown at implant site. Advice patient to keep incision clean and dry .Encourage tub bathe rather than showers for first 10 days after pacemaker implantation.

82. Instruct patient not to scrub incision site or clean site with bath water. Teach patient to clean incision sites with antiseptic as directed. Explain to the patient the healing will take approximately 3 months. Instruct patient to maintain a well balanced diet to promote healing. Inform patient that there is no increased risk of endocarditis with dental cleaning or procedure so antiobiotic prophylaxis is not necessary.

83. Follow up: Make sure that the patient has a copy of ECG tracing (according to facility policy) for future comparasion .Encourages patient to have regular pacemaker checkup for monitoring function and integrity of pacemaker. Inform patient that transtelephonic evaluation of implanted cardiac pacemaker for battery and electrodes failure is available. Review medication with patient before discharge. Inform patient that the pulse generator will have to be surgically removed to place battery and that it is a relatively simple procedure performed under local anesthesia.

84. summary

85. Conclusion

86. bibliography