Reviews, contraindications and installation of a heart pacemaker

What is a pacemaker and how does it work?

A pacemaker (pacemaker) is a medical device designed to encourage or impose a normal rhythm on patients whose heart rate is not fast enough or there is a blockade of signal transmission between different parts of the organ. It is a small-sized device measuring 3 by 5 centimeters, weighing 30-45 grams, the service life without replacing batteries varies from 5 to 15 years.

The principle of operation of the device is based on the application of external electrical stimuli to the area of ​​the heart, which is produced by the pacemaker, to ensure the normal contraction of the myocardium. Advanced (frequency-adaptive) pacemakers additionally have sensory sensors capable of responding to changes in respiration rate, nervous system activity and body temperature. There are also pacemakers with a defibrillator. Modern models have the function of non-invasive replacement of operating parameters using special devices.

A chip embedded in the device analyzes the signals generated by the heart, transmitting them directly to the myocardium and providing them with synchronization. The conductors implanted under the endocardium are transmitters of information from the external part of the device to the heart and data on the work of the myocardium itself back. The end of each electrode is equipped with a metal tip that collects indicators of cardiac activity and generates impulses only when necessary. With the development of a critical decrease in the heart rate or asystole, the pacemaker begins to work in a constant mode, producing stimuli with a frequency set during its implantation. If there was a sudden resumption of the automaticity of the heart, the device goes into a standby state.

In emergency cases, temporary pacing is used. With an external (transthoracic) pacemaker, electrodes are placed on the chest. Since the procedure is very painful, it requires deep sedation and pain relief. Transesophageal manipulation involves the installation of a temporary apparatus in the esophagus, and therefore has limited use.

Classification of artificial pacemakers

Several types of pacemakers are distinguished depending on the zone of exposure:

1. Single-chamber EKS. It is located and stimulates contractions only in one of the chambers of the heart (atrium or ventricle). The use of this device is very limited because it does not satisfy the physiological function of the muscle. Apply it in the presence of a constant form of atrial fibrillation, set in the right ventricle. Disadvantages: the atria continue to work in their own rhythm and when their contractions coincide with the ventricular ones, a reverse blood flow occurs, bringing it to the heart.
2. Two-chamber EKS. The electrodes are placed in two chambers of the heart: the generation of an impulse alternately causes contractions of the atria and ventricles, ensuring the physiological work of the myocardium. When using such a pacemaker, the frequency mode is individually selected, which improves the patient's adaptation to physical activity.
3. Three-chamber ECS is one of the newest and most expensive developments. The impulse conductors are placed in the right atrium and ventricles. It is used to eliminate chamber desynchronization in severe bradycardia, third-fourth degree heart failure, rigid sinus rhythm.

International device coding

The first letter of the code designates the cardiac chamber being stimulated, the second - the cavity, the electrical activity of which is read by the pacemaker. "T" in the third position means that the device operates in trigger mode (artificial signals are synchronized with the discharges generated by the heart). The designation "D" (dual - TI) indicates that a pacemaker with two electrodes in the right heart is operating simultaneously in two modes. The symbol "O" characterizes the "asynchronous" rhythm of the pacemaker functioning (the pulse frequency is set automatically during implantation).

Defibrillator cardioverter

An implanted cardioverter defibrillator (ICD) is a mini-copy of the device used during resuscitation in case of cardiac arrest. Since the device has direct access to the myocardium, much less discharge force is required for effective contraction.

The ICD is intended to prevent sudden cardiac arrest in patients with paroxysmal arrhythmias (fibrillation and ventricular tachycardia).

The ICD system is equipped with electrodes fixed under the patient's endocardium and directly with a device equipped with a microcircuit and a long-term charge battery, which is implanted into the subcutaneous fat on the chest.

The device carries out:

• constant monitoring of cardiac activity;
• collection of contractility parameters;
• in case of life-threatening rhythm disturbances - treatment.

Indications and age-related contraindications: who needs the device and why?

TO absolute indications include:

• persistent bradycardia with characteristic clinical signs;
• documented decrease in heart rate <40 beats / min. during physical work;
• episodes of lack of rhythm (asystole) on the ECG lasting more than three seconds;
• a combination of stable II-III degree AV block with impulse conduction delays in two or three His bundles in patients with postinfarction cardiosclerosis;
• any types of bradyarrhythmias that can threaten the patient's health or life (if the heart rate is less than 60 beats / min.);
• paroxysms of ventricular arrhythmias (tachycardia, fibrillation, asystole).

Relative indications:

• AV block II-III degrees without changing the patient's condition;
• loss of consciousness in patients with blockages without a connection with ventricular tachycardia with an unknown cause of arrhythmia;
• severe circulatory failure with asynchronous work of the ventricles (with atrial fibrillation, myocardial infarction).

There are no age-related contraindications for installing a pacemaker. The only limitation is the unreasonableness of the operation.

Installing a pacemaker: how is the operation going?

Before the intervention, the patient needs to undergo a series of instrumental examinations:

• ECG with a description;
• daily monitoring according to Holter;
• Echocardiography;
• survey radiography of the OGK;
• veloergometry, treadmill test;
• transesophageal study of the cardiac conduction system.

The implantation of a pacemaker or cardio defibrillator is considered a minimally invasive and minimally traumatic procedure that does not require deep anesthesia and is performed under local anesthesia. If necessary, the patient can be administered additional sedatives, but the patient is constantly awake and can talk with the medical staff. The procedure is carried out in a special operating room with an X-ray apparatus for constant monitoring of the position of the electrodes. Duration - from 30 minutes to 1.5 hours.

Under X-ray control, puncture of the subclavian vein is performed on the side opposite to the leading arm (on the left for right-handed people and vice versa). Through a central catheter fixed on the skin, thin electrical probes are inserted into the heart cavity, which will conduct impulses from the subcutaneous part of the apparatus to the heart.After attaching the electrodes, the cardiologist performs a series of tests to determine the threshold of myocardial sensitivity to signals, in response to which an effective contraction should follow.

Throughout the procedure, the electrocardiogram is continuously recorded and decoded.

During the operation, the doctor asks the patient to perform some tests to make sure that the electrodes are securely attached to the endocardial layer of the heart wall - take a deep breath, cough, and slightly tighten the abdominal muscles. After calibrating the optimal ECG indicators, the conductor is finally fixed and connected to the outdoor unit.

The body of the pacemaker is implanted in a pocket made of fatty tissue or under the sternum muscle in lean patients. After connecting all the wires, the "bed" is sutured tightly with self-absorbable sutures.

To prevent complications, a sterile bandage is applied to the vein puncture site and a prophylactic course of broad-spectrum antibiotics is prescribed.

The first 24 hours requires strict bed rest (there is a risk of displacement of the conductors inside the heart). The patient is under the round-the-clock supervision of the doctor on duty. On the second day, X-ray control of the installed device is performed, the EKS system is set up (the operation of the device is optimized depending on the patient's own rhythm), and daily electrocardiographic monitoring is performed.

Immediately after the operation, abrupt movements should be avoided: hand swings on the side of implantation, quick getting out of bed, tilting the body, coughing. Also, do not sleep on your stomach, putting pressure on the place where the stimulator was installed.

Features of implantation in the elderly

The pacemaker can be installed in a patient of any age. The only nuance inherent in the elderly is the increased risk of rejection due to an immune response to a foreign object. Due to the combined pathology (presence of atherosclerosis, diabetes mellitus of the second type), the level of complexity of the apparatus installation increases, the procedure for implantation and postoperative scar healing is lengthened. The likelihood of developing purulent complications does not depend on the patient's age. The doctor takes into account all the pros and cons of installing each type of heart pacemaker for a particular patient and chooses the safest option.

How to live after the intervention?

The low trauma of the procedure allows the patient to be discharged from the hospital for 3-5 days. The time spent in the hospital is necessary to adjust the optimal operation of the pacemaker, prevent postoperative complications, and select adequate therapy for the patient's heart disease (dose reduction or complete withdrawal of the drug).

During the first 4-6 weeks, the patient may feel a slight tingling sensation at the device implantation site. These are micro-discharges that excite tissues. Often, tingling and discomfort disappear on their own, sometimes reprogramming of the device is required. The rehabilitation period lasts 7-14 days. For 7-10 days, a prophylactic dose of antiarrhythmic drugs is prescribed. Patients at this stage should avoid heavy emotional stress and physical labor.

After two weeks, the person returns to their previous life activity and can start work, and young women can get pregnant and give birth to a child.

There are several prohibitions in professional activity:

• work with heavy vibrating tools;
• with high-frequency heating devices;
• with devices for electric carbon welding, induction furnaces;
• with electrical appliances with a strong magnetic field or high voltage lines;
• with an electric welding machine;
• on radio and television towers.

After discharge from the hospital, several rules must be strictly observed:

• take medications prescribed by a cardiologist;
• adhere to the schedule of visits to check the work of the ECS;
• with you at all times to have a card of a patient with an implanted pacemaker.

After three, six months, and then every year, the patient must undergo a follow-up examination by a doctor and check the condition of the pacemaker using a special device that programs the operation of the device. ECS check consists of:

• analysis of the position of the electrodes;
• evaluating the optimality of the program;
• checking the battery charge, forecasting the date of replacement of the power source;
• elimination of emerging complications, patient education.

As the pacemaker's power supply gets closer to replacing, the frequency of doctor visits will increase.

There are several nuances for patients with CDI:

• driving with extreme caution;
• it is not recommended to wear a mobile phone over an implanted mechanism;
• do not linger between the frames of security gates in shops and airports;
• it is forbidden to conduct MRI studies, medical manipulations with the use of certain instruments (electrocautery, diathermy, external defibrillator, ultrasound lithotripsy, radiofrequency ablation, radiation therapy).

Patient prognosis

Establishing an artificial pacemaker can prolong a patient's life for decades and significantly improve its quality.

The disability of a patient with EKS can only be established if his complete dependence on the device is proved. For this purpose, it is necessary to conduct a forensic medical and social examination (MSE), during which the patient's health status and the degree of circulatory failure will be assessed. Also, to prove dependence on the pacemaker, you need to temporarily turn off the device with an electrocardiogram recording. In the presence of asystole lasting more than 5 seconds (or for 2 seconds, followed by a rhythm of less than 30 beats / min.), The person is considered completely dependent on the device. If the heart rate is> 40 beats / min. the assignment of a disability group will be denied.

Pacemaker and long journeys

There are no travel restrictions for people with pacemakers. After three months, patients can freely fly an airplane with a pacemaker. To travel safely, you must adhere to a number of rules:

1. Plan a trip 3 months after the pacemaker implantation.
2. Undergo training in the rules of conduct in the event of a breakdown of the apparatus.
3. Indicate the presence of an artificial pacemaker to the tour operator, take out insurance.
4. Take with you the card of the patient with the ECS (at the airport, it provides for the passage of manual inspection instead of the magnetic frame).
5. Do not stay inside the detector for more than 15 seconds.
6. Find several nearby medical facilities where they can provide assistance in an emergency.

People with an artificial pacemaker can drive a car without hindrance. The only precaution is that if you need to travel for a long time behind the wheel, it is recommended to wrap the seat belt straps with a towel to reduce the load on the site of the pacemaker implantation.

Sex, bath and other entertainment after implantation: when and to whom is it possible?

Patients with an established pacemaker have no restrictions on diet and alcohol intake. But you should adhere to the dietary recommendations for cardiac pathology and drink alcohol in moderation. Two weeks after the implantation of the pacemaker, if the patient feels well, the patient can return to sexual activity.

Patients with pacemaker can play sports with the exception of:

• contact types (football, martial arts);
• scuba diving, scuba diving;
• shooting sports (the recoil of the stock can damage the contacts or the body of the device).

Doctors' recommendations differ regarding relaxation in the sauna.Some categorically prohibit visiting the steam room, others are of the opinion that a short stay in the bath is possible after three months from the time of the operation. In any case, it is necessary to build on the condition of a particular patient.

Consequences and complications of the operation

Implantation of an artificial heart rate driver is a surgical intervention in which there is a possibility of complications:

• perforation of the myocardial wall;
• venous bleeding;
• pneumothorax;
• subclavian vein thrombosis.

In the recovery period, development is possible:

• infectious inflammation of the area where the pacemaker is mounted;
• endocarditis;
• conductor migration;

• pacing syndrome.

The latter develops in patients with an established single-chamber pacemaker. The violation is based on the asynchronous contraction of the atria and ventricles, as a result of which the diastolic filling of the heart cavities decreases - the patient's symptoms of heart failure are increasing. Pacemaker syndrome requires additional studies (X-ray, Holter rhythm monitoring) and reprogramming of the apparatus.

In rare cases, after ICD placement, shocks may be generated at a normal rhythm, or cardioversion may be absent when necessary. The main causes of the malfunction are: migration of the electrode inside the cardiac cavity, an increase in the threshold of sensitivity to impulses, or a complete discharge of the power supply.

Symptoms that require medical attention:

• fever, redness of the postoperative scar, pain, swelling, fluid, pus;
• uncharacteristic sensations in the area of ​​the pacemaker;
• dyspnea;
• attacks of dizziness, loss of consciousness;
• decreased exercise tolerance;
• constant fatigue, drowsiness;
• chest pain;
• constant hiccups;
• an increase in swelling of the legs;
• palpitations;
• decrease in heart rate below the programmed level.

Dislocation of the electrode

The situation is a displacement of the position of the electrode relative to the zone of its installation. Most often occurs in the first day or several weeks after surgery. The electrocardiographic picture will depend on the position of the detached conductor:

• disordered unresponsive stimuli with imposed complexes;
• failure of synchronization and stimulating function of the device;
• stimulation of the atrium or phrenic nerve.

Symptoms of the dislocation of electrodes in a pacemaker are manifested in the form of an increase in the phenomena of heart failure and require immediate correction of the position of the conductors or their complete replacement.

Despite positive feedback from patients about pacemakers, an artificial driver or cardioverter-defibrillator is implanted in order to correct the heart rate, and this does not eliminate the root cause of the violation.

Conclusions

Inserting a pacemaker is a simple and relatively safe operation that can increase the life expectancy of patients with severe arrhythmias and sudden cardiac death.

The cost of a pacemaker and its installation is very high. Moreover, it requires careful maintenance and regular change of nutrients, but often intervention is the only chance to continue the usual way of life.