Pacemaker implantation.

pacemaker

1. PACEMAKER IMPLANTATION Submitted by : Iffat Parveen Class - BPT 4 TH Year Submitted to : Dr. Jamal Ali Moiz Date of Presentation – 29.12.2020 Subject - BPT 402 Physiotherapy In Cardiopulmonary Conditions Department- Centre For Physiotherapy and Rehabilitation Sciences Jamia Millia Islamia

2. The Heartbeat The heart is the most important muscle in the body. It has a right and a left side. Each side has 2 chambers: an atrium and a ventricle. Blood comes from the body to the right atrium. From there, it is pumped to the right ventricle. The right ventricle pumps the blood to the lungs. In the lungs, the blood is loaded with oxygen. From the lungs, the blood goes to the left atrium and then to the left ventricle. From there, it is pumped to the rest of the body and the cycle repeats. A normal heart rate varies between 60 to 100 beats per minute when a person is at rest. The heartbeat starts when the heart receives an electrical signal. The electric current in the heart starts in an area of the right atrium called the sinus node. It causes the atria to contract and pump blood to the ventricles. From the sinus node, the electric current travels through fibers that are similar to electric cables. Through the fibers, the electric current arrives in another area of the heart called the atrio-ventricular node, or AV node. From the AV node, the electric current spreads to the ventricles and causes them to contract and pump blood. Each electrical signal results in one heartbeat. Any interruption to the normal flow of electrical signals in the heart results in an abnormal heart rhythm. Arrhythmias Any change in the normal rhythm of the heart is called an arrhythmia. Most arrhythmias result from problems in the electrical system of the heart. Problems in the heart’s electrical system can be caused by flaws in the sinus node, AV node, or any other part of the electric wiring of the heart. Problems in the electrical make-up of the heart can be caused by: Heart attacks Valve problems Valve replacement surgery As long as the heart beats normally, blood flow to the body is not disrupted. If the heart beats too fast or too slow, blood flow to the body will usually decrease greatly. This can lead to dizziness, fainting, chest pain, and difficulty in breathing. Arrhythmias are usually treated with medication. When treatment does not work for the kind of arrhythmias that slows down the heart, a pacemaker may be necessary.

3. What is a p acemaker A pacemaker is a small, battery-powered device that delivers mild electrical signals to your heart to help it beat at a normal rate and pump more effectively. When a pacemaker detects an abnormal heart rhythm, such as low heart rate, the device sends an electric pulse to your heart. The pulse stimulates your heart to beat faster, keeping its beat at a normal rate. Components of pacemaker All cardiac pacemakers consist of 2 components: a pulse generator ( which has a battery and a tiny computer circuit) which provides the electrical impulse for myocardial stimulation and 1 or more electrodes or leads ( known as pacing leads) which deliver the electrical impulse from the generator to the myocardium. Each impulse causes the heart to contract. The pacemaker may have one to three leads, depending on the type of pacemaker needed to treat your heart problem

4. INDICATIONS : Guidelines for implantation of cardiac pacemakers have been established by a task force formed jointly by the American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Rhythm Society (HRS). The European Society of Cardiology has established similar guidelines. ACC/AHA/HRS divides indications of pacemaker implantation into 3 specific classes: Class I: These are conditions where implantation of a pacemaker is considered necessary and beneficial (benefits much greater than risks). Class II: These are conditions where placement is indicated, but there is conflicting evidence or divergence of opinion. In Class IIa weight of evidence is in favor of efficacy (benefits greater than risk), while in class IIb, the efficacy is less well established (benefits ­greater than or equal to the risks). Class III: These are conditions in which permanent pacing is not recommended, and in some cases, it may be harmful (risks greater than the benefits). Following conditions are included in the ACC/AHA/HRS guidelines for the pacemaker insertion : Sinus node dysfunction Acquired Atrioventricular(AV) block Chronic bifascicular block After acute phase of myocardial infarction Neurocardiogenic syncope and hypersensitive carotid sinus syndrome Post cardiac transplantation

5. Hypertrophic cardiomyopathy Pacing to detect and terminate tachycardia Cardiac resynchronization therapy in patients with severe systolic heart failure  Patients with congenital heart disease CONTRAINDICATIONS : These are sometimes also called class III indications in ACC/AHA/HRS guidelines or European Society of Cardiology guidelines. Sinus bradycardia without significant symptoms; asymptomatic first-degree AV block. AV block that is expected to resolve and unlikely to recur example drug toxicity, Lyme disease, or transient increase in vagal tone A pacemaker is not indicated for sinus node dysfunction in patients with symptoms suggestive of bradycardia that have been documented to occur even in the absence of bradycardia. Asymptomatic second-degree Mobitz, type-I block Asymptomatic prolonged RR interval with atrial fibrillation or other causes of transient ventricular pauses Hypersensitive cardioinhibitory response to carotid sinus stimulation in the absence of symptoms or in the presence of vague symptoms such as dizziness, lightheadedness Asymptomatic bradycardia during the sleep CRT is not indicated in patients whose functional status and life expectancy are limited predominantly by non-cardiac conditions

6. Right bundle branch block with left axis deviation without syncope or other symptoms compatible with intermittent AV block Long QT syndrome due to reversible causes In the presence of an accessory pathway that has the capacity for rapid anterograde conduction Patients with NYHA class I or II symptoms and non-LBBB pattern with QRS duration less than 150 ms

7. Types of pacemakers There are different types of  pacemakers: Single-chamber pacemakers use one lead in the upper chamber (atria) or lower chamber (ventricles) of the right side of the heart. Dual-chamber pacemakers use one lead in the right atrium  and  one lead in the right ventricle of your heart. Biventricular pacemakers  use three leads: one placed in the right atrium, one placed in the right ventricle, and one placed in the left ventricle (via the coronary  sinus vein).

8. Before the Procedure Your doctor will discuss the implantation with you prior to the procedure. Once you and your doctor have discussed the procedure and you've had any questions answered, you'll be asked to sign an informed consent form. You won't be allowed to eat or drink for eight hours prior to the procedure.  We will instruct you if you need to stop any medications before the procedure . Pacemaker Insertion Process Generally, a pacemaker insertion follows this process: Patients will be asked to remove any jewelry or other objects that may interfere with the procedure Patients will be asked to remove clothing and will be given a gown to wear Patients will be asked to empty their bladder prior to the procedure An intravenous (IV) line will be started in the hand or arm prior to the procedure for injection of medication and to administer IV fluids, if needed Patients will be placed in a supine (on back) position on the procedure table.

9. Patients will be connected to an  electrocardiogram (ECG or EKG) monitor that records the electrical activity of the heart and monitors the heart during the procedure using small, adhesive electrodes. Vital signs (heart rate, blood pressure, breathing rate, and oxygenation level) will be monitored during the procedure Large electrode pads will be placed on the front and back of the chest Patients will receive a sedative medication in IV before the procedure to help patients relax. However, patients will likely remain awake during the procedure The pacemaker insertion site will be cleansed with antiseptic soap Sterile towels and a sheet will be placed around this area A local anesthetic will be injected into the skin at the insertion site Once the anesthetic has taken effect, the doctor will make a small incision at the insertion site A sheath, or introducer, is inserted into a blood vessel, usually under the collarbone. The sheath is a plastic tube through which the pacemaker lead wire will be inserted into the blood vessel and advanced into the heart

10. It will be very important for patients to remain still during the procedure so that the placement will not be disturbed and to prevent damage to the insertion site The lead wire will be inserted through the introducer into the blood vessel. The doctor will advance the lead wire through the blood vessel into the heart . Once the lead wire is inside the heart, it will be tested to verify proper location and that it works. There may be one, two, or three lead wires inserted, depending on the type of device the doctor has chosen for the patient’s condition. Fluoroscopy, (a special type of X-ray that will be displayed on a TV monitor), may be used to assist in testing the location of the leads Once the lead wire has been tested, an incision will be made close to the location of the catheter insertion (just under the collarbone). Patients will receive local anesthetic medication before the incision is made The pacemaker generator will be slipped under the skin through the incision after the lead wire is attached to the generator. Generally, the generator will be placed on the non-dominant side. (If patients are right-handed, the device will be placed in the upper left chest. If patients are left-handed, the device will be placed in the upper right chest) The ECG will be observed to ensure that the pacer is working correctly The skin incision will be closed with sutures, adhesive strips, or a special glue A sterile bandage/dressing will be applied

11. After the Procedure If the procedure is performed on an outpatient basis, patients may be allowed to leave after completing the recovery process. However, if there are concerns or problems with the ECG, patients may stay in the hospital for an additional day (or longer) for monitoring of the ECG. Patient may be admitted to the hospital overnight. The nurses will monitor his heart rate and rhythm. Patients should be able to return to their daily routine within a few days. The doctor will tell you if you will need to take more time in returning to normal activities. In addition,. Do not lift objects that weigh more than 10 pounds. Do not hold your arm above  shoulder  level for three weeks. Avoid activities that require pushing or pulling heavy objects, such as shoveling the snow or mowing the lawn. Stop any activity before you become overtired. Avoid golfing, tennis, and  swimming for 6 weeks after the procedure. Try to walk as much as possible for  exercise . Ask your doctor when you can resume more strenuous activities. Your doctor will tell you when you can go back to work, usually within a week after you go home. If you have the flexibility at your job, ease back to your regular works schedule

12. Patients will most likely be able to resume their usual diet, unless the doctor instructs differently. Patient will be shown and instructed how to care for your wound. Keep the wound clean and dry. Look at your wound every day to make sure it is healing. Symptoms - Medical emerygency You should lie down immediately, make sure you are in a safe environment, away from any machines or moving vehicles, and call a friend or family member, if you feel any of the following symptoms: Lightheadedness Fast heart rate (palpitations) Dizziness Chest pain Shortness of breath Fainting or near fainting (syncope)

13. Avoid Certain Electrical Devices With a Pacemaker : Electric blankets, heating pads, and microwave ovens can be used and will not interfere with the function of your pacemaker. Cell phones should not be placed directly against the chest or on the same side as your pacemaker. You will need to avoid strong electric or magnetic fields, such as some industrial equipment; ham radios; high intensity radio waves (found near large electrical generators, power plants, or radiofrequency transmission towers); and arc resistance welders. Do not undergo any tests that require magnetic resonance imaging (MRI). When going through airport security, show your pacemaker card without going through the screening machine because the pacemaker will set off the security alarms. Your doctor or nurse can provide more information about what types of equipment may interfere with your pacemaker. If you have concerns about your job or activities, ask your doctor. How Long Will the Pacemaker Last? Pacemakers may last five to 10 years and sometimes longer, depending on how often they are used. When the battery becomes low, it will need to be changed. FOLLOW UP: A complete pacemaker check should be done six weeks after your pacemaker is implanted. This follow-up appointment is critical, because adjustments will be made that will prolong the life of your pacemaker. Then your pacemaker should be checked every three months on the telephone to evaluate battery function. Your nurse will explain how to check your pacemaker using the telephone transmitter. Once or twice a year you will need a more complete exam.

14. If you have a biventricular pacemaker, you may need to visit the doctor's office or hospital more frequently to make sure your device is working properly and the settings do not need to be adjusted. COMPLICATIONS: The majority of complications occur in the hospital or during first 6 months. Lead complications are the main reason for the re-implantation of the pacemaker and CRT devices. Other complications include, but are not limited to: infections, hematoma formation, pericardial effusion or tamponade, pneumothorax, coronary sinus dissection, or perforation. Some old pacemakers are not MRI safe.  Getting a pacemaker implanted: The procedure to implant a pacemaker does not require open heart surgery, and most people go home within 24 hours. Before the surgery, medication may be given to make you sleepy and comfortable. Generally, the procedure is performed under local anesthesia.

15. Cardiac rehabilitation Cardiac rehabilitation is a widely accepted management for chronic heart failure patients, particularly those who have been implanted with a CRT device. However, cardiac rehabilitation should be seen as a comprehensive global management. In this way, the following contribute to the benefits of cardiac rehabilitation : medical treatment adjustments, patient education, nutrition counseling, psychosocial support and exercise training As both endurance training and CRT improve exercise tolerance in heart failure patients, the combination of the two types of management enhances the benefits. So, after a CRT implantation, referral to a cardiac rehabilitation program improves exercise capacity, hemodynamic status, quality of life, quality of sleep, and reduces depression and endothelial dysfunction .

16. Exercising prescription w ith a Pacemaker or Implantable Cardioverter Defibrillator: Exercise plays an important role in rehabilitation after implantation of a pacemaker or other cardioverter defibrillator because it will counteract the deconditioning that occurred prior to implantation, and reduce your risk factors for heart disease, including high blood pressure and cholesterol, diabetes and obesity. The key to maximizing the benefits of exercise is to follow a well-designed program that you can stick to over the long-term. Aerobic Activity Aerobic activity increases your heart rate and breathing. Build up to doing at least 150 minutes/week of moderate-intensity activity (such as a brisk walk, light cycling or water exercise). You’ll improve your stamina and heart health Activity- Any rhythmic, continuous activity Frequency- 3-5 days a week Intensity - Fairly light to somewhat hard Duration- Start w/5-10 mins. Gradually build up to 20-60 minutes.

17. Aerobic Activity Tips and Cautions When starting a new (or returning to a previous) program, begin with light to medium effort. If you monitor your heart rate during exercise, ask your health care provider what heart rate limits are appropriate for you. Gradually increase your pace and time spent being active. Start low and go slow! Warm up and cool down before and after exercise. Strength Training Strength training can help your muscles work better and increases your strength for daily and recreational activities. Activity - Hand weights, resistance bands, weight machines, or your own body; for example, kitchen counter push - ups or chair sit-to-stands. Frequency - 2-3 days/week. Rest day in between Intensity- Start with light effort. Build up to medium effort. Duration - 10-15 repetitions (for each major muscle group). Perform 1-3 times. Endurance Training Endurance training may use continuous and/or interval or intermittent training models, 3 to 5 days/week, during 30 to 60 min, associated with dynamic exercises.

18. Other Types of Physical Activity Flexibility- Stretch your muscles 2-3 days/week (or every day) to the point of feeling tightness. Hold for 10-30 seconds(30-60 seconds for older adults). For example, stretch your calves or the back of your thighs. Yoga, Tai Chi and Pilates - All help balance, flexibility and strength, and are relaxing too! Just for Fun - Find ways of being active that are just plain fun. Try pickleball or ping pong. Dance. Tend your garden. Play outdoors with your kids /grandkids. Take More Steps - Use a smart phone or activity tracker. Count your steps each day for the first few weeks. Slowly build to 2,000 more daily steps than you’re doing now. Then aim for 7,000-9,000 steps/day.

19. Summary Cardiac pacemaker is a small battery-powered device that delivers mild electrical signals to your heart to help it beat at a normal rate and pump more effectively, used most commonly for bradycardia, heart block it consists of two components- pulse generator and leads How is a traditional pacemaker system implanted - A small incision, approximately 5 cm long, is made in the upper chest.A lead (thin insulated wire, like a spaghetti noodle) is guided through the vein into the heart. The doctor connects the lead to the pacemaker and programs the device.The pacemaker is then inserted beneath the skin.The doctor tests the pacemaker to ensure it is working properly.The incision is then closed. As it is not an open heart surgery patient may be allowed to return home within 24 hrs of the procedure. Follow up after six week need to be followed after the procedure,earlier (3 weeks)if required Physiotherapy rehab is followed.

20. References: www.hopkinsmedicine.org Pacemaker indications- www.ncbi.nlm.nih.gov ACC/AHA Guidelines for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices:A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines- www.ahajournals.org www.standfordhealthcare.org Cardiac Rehab – www.monaldi-archives.org Excerice prescription- www.exerciseismedicine.org