Device Clinic

Device Clinic

 

The Peterborough Regional Cardiac Rhythm Device Clinic provides follow-up for patients with Cardiac Implantable Devices such as Loop Recorders, pacemakers and Implantable Defibrillators. Registered Nurses and Cardiovascular Technologists who have special training and expertise in managing the devices and patients with cardiac rhythm problems, staff the clinic under the supervision of our Cardiologists. The clinic is open Monday to Friday from 8am to 4pm all working days of the year.

Current Advisories


The following advisories are from the Canadian Heart Rhythm Society about certain implantable ICDs and Pacemakers


ADVISORY


Apple Inc. iPhone 12 Series





ADVISORY


BIOTRONIK – Urgent Field Safety Notice – Potential premature battery depletion in a subset of ICD and CRT-D devices





ADVISORY


Abbott – Voluntary Medical Device Recall Urgent – For a subset of ASSURITY™ and ENDURITY™ pacemakers
MODELS PM1160, PM1172, PM1240, PM1272, PM2160, PM2172, PM2240, PM2260, PM2272

 





ADVISORY


Boston Scientific EMBLEM S-ICD Subcutaneous Electrode (Model 3501). (Boston Scientific Field Action Reference: 92384167-FA)





ADVISORY


Premature Battery Depletion with St. Jude Medical ICD and CRT-D devices manufactured before May 23, 2015. Affected models include Fortify™, Fortify Assura™, Quadra Assura™, Quadra Assura MP™, Unify™, Unify Assura™ and Unify Quadra™.





ADVISORY


Potential for Premature Battery Depletion in a Subset of Medtronic ICD and CRT-D Devices:
Claria MRI™/Amplia MRI™/Compia MRI™/Viva™/Brava CRT-Ds™/Visia AF™/Visia AF MRI™/Evera™/Evera MRI™ ICDs




Information


Information and Answers to your Questions about Cardiac Pacemakers, ICD, and Loop Recorders



Overview


A Pacemaker or Pulse Generator, is a small metal container that houses a battery and the electrical circuitry that regulates the rate of electrical pulses sent to your heart. It is placed under the skin in your chest to help control your heartbeat. It is used to help your heart beat more regularly if you have an irregular heartbeat (arrhythmia), particularly a slow one. Implanting a pacemaker in your chest requires a surgical procedure. Pacemakers work only when needed. If your heartbeat is too slow (bradycardia), the pacemaker sends electrical signals to your heart to correct the beat.

 

Types of pacemakers

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.
  • Leads (electrodes) – One to three flexible, insulated wires are each placed in a chamber, or chambers, of your heart and deliver the electrical pulses to adjust your heart rate. They connect to the Pulse Generator.

 

A Defibrillator (also know as an ICD) is also a Pacemaker but has an added ability to treat fast, life threatening heart rhythms. It does this by either pacing the heart rapidly or shocking the heart when such a rhythm is detected. It has a wide variation of “programs” and that program will be individualized to your particular heart rhythm problem. These devices are best managed by Remote Monitoring and occasional Clinic visits.

A Loop Recorder is a very small implanted device that records your heart rhythm. It is used to uncover conditions that may be giving symptoms and have not yet been diagnosed. It does not treat any rhythm condition. Information can be downloaded when you visit the Clinic. It is usually removed after diagnostic information has been attained.



Preparing for Surgery


Prior to your procedure, your doctor will review your medical history. He or she will also explain the purpose of the defibrillator, pacemaker or implantable Loop recorder, its potential benefits and possible risks. The risks of implanting a defibrillator, pacemaker or loop recorder are small and relatively safe. Most patients undergoing these procedures do not experience complications.

You will need to have a blood test, ECG and Chest X Ray, before the procedure and you may need to be seen by the anesthetist. Your doctor’s office or the Surgeons office will arrange these for you.

Take a shower the night before or the morning of your surgery.

Please bring with you all of your current medications or an accurate pharmacy list of them.

You can have NOTHING to eat or drink from midnight the night before your procedure. Take your morning medications as usual. The exception to this may be a blood thinner or diabetic medication. You may be given specific instructions on how to handle this. Medications can be taken with a sip of water unless you are instructed otherwise.

Blood Thinners such as Coumadin® (Warfarin), Pradaxa® (Dabigatran), Eliquis® (Apixaban) and Xarelto® (Rivaroxaban) are usually stopped 1 – 3 days before the procedure. You will be given specific instructions about what to do by your doctor or the Surgeon.

If you take any medication (pills or insulin) for your diabetes, ask for instructions from the Surgical office or from your doctor about medication and food the day of the surgery.

If you need an interpreter, bring a friend or family member on the day of the procedure. You’ll be sedated during this procedure. Your friend or family member will be instructed on how to care for you or assist with your care after the procedure on discharge and will be required to drive and/or accompany you home. They can also help you gather information, take notes and ask questions.

You will not require any personal items for your surgical day. DO NOT bring large sums of money or valuables to the hospital.

You will require a driver to pick you up and someone to stay with you during the night, after you have had your procedure.



The Procedure to Implant a Pacemaker, An ICD or a Loop recorder


The surgery is done in the operating room or Heart Catheterization Lab. The environment is kept cool to keep the machines working properly, so you may feel cool as well. During the procedure, the nurses will monitor your heart rhythm and blood pressure. Sterile sheets will be put on you to keep the insertion site clean.

Surgery usually takes 1 – 2 hours; however, you will be here all day. Most patients are discharged the same day, but an overnight stay can last 1 – 2 days.

We do everything that we can to stay on time. Unfortunately, your appointment may be delayed by unforeseen circumstances. We recommend that you come prepared for delays.

Currently, only Pacemakers and Loop recorders are implanted in Peterborough. ICDs are referred elsewhere for implant but can return to the Peterborough Device Clinic for follow-up.

You will be instructed by the Vascular Surgeons office of your arrival time and location of check-in at Peterborough Regional Hospital.

Most procedures are done with local anaesthetic or freezing plus some medication to help you relax. Once you are sedated, the surgeon will make two incisions. The first is to implant the lead(s). One end of the lead goes in your heart. The other will be plugged into the Defibrillator or Pacemaker. The second incision makes a “pocket” or pouch just under your skin.

The basic surgical procedure involves: inserting the leads; testing the leads to ensure the best position on or in the heart; connecting the leads to the defibrillator or pacemaker device; testing the automatic function of the device; closing the incision; programming the device.

When you wake up from the anaesthetic, you will be drowsy and feel some discomfort. You will be in the recovery room for approximately 1 hour before returning to your room or on the Short Stay Unit.

When you return to your room, you’ll be allowed to have something to eat and drink. You will be connected to a telemetry monitor to monitor your heart and its activity until you are discharged from the hospital.

The nursing staff will monitor your heart rhythm and respiration rate and provide medication to control pain at the site of the incision.

At home pain or discomfort should be managed with Tylenol or Advil.



Device Replacement Surgery


A pacemaker generator change, sometimes called a battery replacement, is necessary because the pacing device is at the end of its service life. The remaining lifespan of a pacemaker is determined during visits to the Pacemaker Clinic. The battery in a pacemaker does not stop suddenly but rather loses its charge slowly, which lets the cardiologist plan the replacement date. This procedure takes less than one hour.

This will, in all likelihood be a planned procedure. Your Clinic Nurse will give you warning when you are approaching replacement time. They will also let you know if the procedure requires only the Device replacement or if lead(s) need to be replaced. In the majority of cases, it is only the Device that needs to be replaced. The Clinic staff will choose a replacement device and program it to match what you currently have. They will send this to the Hospital for the Surgeon to implant. As in your initial surgery, local anaesthetic will be given, the pocket opened and the lead(s) disconnected briefly to attach the new Device. The pocket will then be closed and stitched much like before. There should be less swelling and bruising than in the original implant and healing should be faster. There are no arm movement restrictions if your leads are not replaced. You will be seen in clinic for wound management and programming in 7 to 10 days. Regular follow-up will resume after that.



What to Expect following Surgery


Recovery time varies between about 4 – 6 weeks. You can return to daily activity gradually. Remember to rest when you are tired. Avoid strenuous activities such as lifting heavy objects, vigorous push-pull movements (vacuuming), above-the-shoulder activities (tennis, golf) and overhead reaching and stretching. You may otherwise have normal range of movement.

You will be given a temporary device Identification (ID) Card that should be carried with you at all times. The permanent card will be mailed to you within four to six weeks. Let your Clinic staff know if you do not receive it. The ID card provides an emergency phone number and information about your device. A letter from The Device Clinic will be given to you following surgery. It describes how to contact the Clinic and the date of your follow up appointment.

If you have a newly implanted Pacemaker or ICD, you should wait until your first follow up appointment to drive. Always wear a seatbelt, even if it crosses over your site. Keep your incision dry.



Caring for your Wound


  • You may take a bath without getting your wound wet
  • Avoid powders, creams and ointments at the incision site
  • Keep your bandage dry-if it falls off, leave it off
  • You may usually remove the outer bandage after 48 hours
  • After 7 days, gently remove any remaining bandage but leave the small strips that cross over the incision
  • Report any signs of infection such as fever, heat at pocket, drainage of increasing pain
  • Attend your appointment at the Clinic at day 8-10 to have any stiches removed, the wound examined and Device Assessment done (this appointment should be given to you in the OR – if not, call 705-775-3333)


What are my options for follow-up?


  • In-Clinic
  • Remote Monitoring (device dependent)
  • Combination of the two

No matter what type of follow up you choose, you will always have your first several appointments in-clinic. This is for the purpose of educating you, checking your incision and pocket and fine-tuning the settings of the device to best suite your heart rhythm and your lifestyle.

Our Device Clinic, at Kawartha Cardiology is specialized. Nurses and technicians, who have received extra training and education in the field, staff this Clinic. They are experts. They work under the direction of a Cardiologist. There is always a Cardiologist in the Clinic and available to see you in the event of any complications or concerns.

Many Pacemakers and ICDs can now be followed remotely from your home or wherever you are. The ability to do this is dependent on the type of device that you have been given.

Remote monitoring involves having a transmitter from the Manufacturer of your device. It sits at your bedside and, through wireless technology, transmits the parameters and rhythms of your heart and your device, while you sleep. If any values are found to be abnormal, a transmission is sent to a monitoring station. In turn, that transmission is forwarded to our Clinic to let us know that you need attention. You may then get a phone call from us. This could all be done without your awareness. There is also the ability for you to initiate a transmission if you are having symptoms of concern. This is the ideal follow up method for those of you with ICD and can also be convenient and helpful in patients with pacemakers.



How often should a pacemaker be checked?


A pacemaker should be checked 1-2 weeks after implant. This is a longer appointment and all aspects of life with your pacemaker will be discussed, your stitch will be removed and some paperwork will be completed. Your next visit will be at 6 weeks and then at 6 months. After that, you will be seen at 6 month to one year intervals or at any time you perceive a problem (see complications).

As the pacemaker approaches replacement time, you may be checked more frequently. Regular follow-up is important after a pacemaker implant.

Your Clinic Nurse or Technician can give you an estimate of remaining battery life at each visit.



What is the normal heart rate?


The normal heart rate range at rest is 60 to 100 beats per minute. It goes up with activity or with stress. The pacemaker is designed to mimic the normal heart beat. Your Clinic staff will set the pacemaker or ICD parameters to meet your specific needs.

ICDs are often implanted exclusively to treat fast heart rhythm. If there is no reason to pace your heart, the pacemaker portion of the ICD will be turned to a very low rate to avoid pacing. Again, this will be explained to you in Clinic.



How long will my Device last?


The battery life of a pacemaker depends on the type of pacemaker. Usually, the battery lasts between six to 15 years. It will depend on how the pacemaker is set and how often you use it. You can be informed about approximate battery remaining when your device is interrogated at each encounter. The leads can last many years and may never need to be replaced. Most people have their battery checked every six to 12 months. This can be done in Clinic or on Remote Monitoring.



What can I do and what should I avoid?


  • Do not put anything with a magnet within 6 inches or 15 cm of your device
  • Cellphones. It’s safe to talk on a cellphone, but keep your cellphone at least 6 inches (15 centimeters) away from your pacemaker. Don’t keep your phone in a shirt pocket. When talking on your phone, hold it to the ear opposite the side where your pacemaker was implanted.
  • Antitheft gates (as in a shop) can interfere with a device-walk directly through them without lingering
  • Power-generating equipment. Stand at least 2 feet (61 centimeters) from welding equipment, high-voltage transformers or motor-generator systems. If you work around such equipment, ask your clinic staff to help determine whether the equipment affects your pacemaker.
  • Medical equipment. Make sure all your doctors and dentists know you have a pacemaker. Certain medical procedures, such as magnetic resonance imaging, CT scans, cancer radiation treatment, electrocautery to control bleeding during surgery, and shock wave lithotripsy to break up large kidney stones or gallstones could interfere with your pacemaker. (Note that there are MRI “safe” pacemakers – enquire if yours is such a model)
  • Security systems. Passing through an airport metal detector won’t interfere with your pacemaker, although the metal in it could sound the alarm. But avoid lingering near or leaning against a metal-detection system.
  • Do not lean over a running motor (Boat, Car, etc.)


What is the most common complication after a pacemaker insertion?


This is a very safe procedure and serious complications are rare. The most common complications are:

  • lead dislodgement (higher rate atrial dislodgment than ventricular dislodgment)
  • infection, bleeding, bruising or hematoma at the site.


How do I know when my Pacemaker or ICD needs attention or adjusting?


Keep any routine appointments you have been given. Seek attention by either initiating Remote Transmission or calling the Clinic in the following circumstances:

  • You become short of breath (unusually so) or light headed and dizzy
  • You feel palpitations
  • You lose consciousness (in this case, notify the Clinic and proceed to Emergency Room)
  • Your pacemaker pocket is hot, draining, painful
  • You have “twitching” at the pacemaker site
  • Persistent hiccoughs
  • You receive a shock from your ICD (see ICD information)


Handling Unexpected Events


Always carry your Identification (ID) Card and always wear your medical alert necklace or bracelet. You should carry a list of medications and dosages with you and keep emergency phone numbers on hand. If you have a defibrillator, know what to do when the device delivers a shock. Inform significant co-workers, travelling companions, and others of the defibrillator. When travelling by air, inform airline security personnel of the device. Encourage family members to take a CPR course.



Devices and end-of-life issues


If you have a Pacemaker or Defibrillator and become terminally ill with a condition unrelated to your heart, such as cancer, it’s possible that your pacemaker could prolong your life. Doctors vary in their opinions about turning off a pacemaker or a Defibrillator in end-of-life situations. It is ultimately your (or your Power of Attorney’s) decision. Talk to them about it.

It is a common and easily misunderstood issue as to whether a pacemaker will keep you alive when it comes time for you to die naturally. When one dies, the heart muscle becomes unresponsive to electrical impulse. The pacemaker may continue to emit an output but it will be ineffective in keeping your heart beating. If you planned on cremation, your pacemaker, will need to be removed.