Indications for artificial pacemaker implantation. Indications for implantation of pacemakers and antiarrhythmic devices

Over the past decades, medicine has reached unimaginable heights. This is especially evident in cardiology and cardiac surgery. A hundred years ago, cardiologists could not even imagine that one day they would be able to not only literally “look” into the heart and see its work from the inside, but also make the heart work in conditions of seemingly incurable diseases, in particular serious disorders heart rate. In such cases, artificial pacemakers are used to save the patient's life.

What types of pacemakers are there?

An artificial heart pacemaker (electrical pacemaker, pacemaker) is a complex electronic device, equipped with a microcircuit that allows you to perceive changes in the activity of the heart muscle and correct myocardial contractions if necessary. Such a device consists of the following parts:

Location of electrodes in the heart

An electrocardiostimulator (ECS) records and interprets a cardiogram, based on which it performs its functions.

Thus, during paroxysm of ventricular tachycardia (frequent rhythm), the cardioverter-defibrillator performs an electrical “reboot” of the heart, followed by imposing the correct rhythm through electrical stimulation of the myocardium.

Another type of pacemaker is an artificial pacemaker (pacemaker), which stimulates myocardial contractions during dangerous bradycardia (slow rhythm), when rare heart contractions do not allow adequate release of blood into the vessels.

In addition to this division, the pacemaker can be one-, two- or three-chamber, consisting respectively of one, two or three electrodes, connected to one or more chambers of the heart - to the atria or ventricles. The best pacemaker today is a two-chamber or three-chamber device.

In any case, the main function of the pacemaker is to identify, interpret rhythm disturbances that can lead to cardiac arrest, and correct them in a timely manner through myocardial stimulation.

Indications for surgery

The main indication for cardiac pacing is the presence of arrhythmia in the patient, which occurs as bradycardia or tachycardia.

To bradyarrhythmias, requiring the installation of an artificial pacemaker include:

1. Sick sinus syndrome, manifested by a decrease in heart rate of less than 40 per minute, and including complete sinoatrial block, sinus bradycardia, as well as brady-tachycardia syndrome (episodes of sharp bradycardia, suddenly followed by attacks of paroxysmal tachycardia),


2. Atrioventricular block II and III degrees (complete block),
3. Carotid sinus syndrome, manifested by a sharp slowing of the pulse, dizziness and possible loss of consciousness when the carotid sinus located in the carotid artery superficially under the skin on the neck; irritation can be caused by a narrow collar, a tight tie or too active head turns,
4. Any type of bradycardia accompanied by Morgagni–Edams–Stokes (MES) attacks—attacks of loss of consciousness and/or convulsions that occur as a result of short-term asystole (cardiac arrest) and can lead to fatal outcome.

To tachyarrhythmias, capable of causing severe complications and requiring artificial cardiac pacing include:

• Paroxysmal ventricular tachycardia,
• Atrial fibrillation ( atrial fibrillation and atrial flutter),
• Frequent ventricular extrasystole, having high risk transition to ventricular fibrillation and flutter.

Video: about installing a pacemaker for bradycardia, the program “About the Most Important Thing”

Contraindications for surgery

There are no contraindications for implantation of a pacemaker for health reasons. The operation can be performed even in patients with acute heart attack myocardium, if the latter is complicated by complete AV block or other severe rhythm disturbances.

However, if this moment vital signs the patient does not, and he can live without a pacemaker for some time, Surgery may be delayed if:

1. The patient has a fever or acute infectious diseases,
2. Exacerbation of chronic diseases internal organs(bronchial asthma, stomach ulcer, etc.),
3. Mental illnesses with the patient's inaccessibility to productive contact.

In any case, indications and contraindications are determined strictly individually for each individual patient, and there are no clear criteria.

Preparation and tests before surgery

The need for cardiac surgery can be emergency, when the patient’s life is impossible without an operation to install a pacemaker, or planned, when his heart can work independently for several months even with rhythm disturbances. In the latter case, the operation is carried out as planned, and before performing it it is advisable to carry out full examination patient.

The list of required tests may vary in different clinics. Basically the following must be done:

• ECG, including daily ECG monitoring and Holter blood pressure, which makes it possible to register even very rare but significant rhythm disturbances over a period of one to three days,
• EchoCG (ultrasound of the heart),
• Blood test for thyroid hormones,
• Examination by a cardiologist or arrhythmologist,
• Clinical tests blood - general, biochemical, blood test for coagulation,
• Blood test for HIV, syphilis and hepatitis B and C,
• General analysis urine, stool test for worm eggs,
• FGDS to exclude gastric ulcer - if it is present, treatment by a gastroenterologist or therapist is mandatory, since after the operation blood thinning drugs are prescribed, but have a destructive effect on the gastric mucosa, which can lead to stomach bleeding,
• Consultation with an ENT doctor and dentist (to exclude foci chronic infection, which can provide Negative influence on the heart, when detected, lesions should be promptly sanitized and treated),
• Consultations with narrow specialists, if available chronic diseases(neurologist, endocrinologist, nephrologist, etc.),
• In some cases, an MRI of the brain may be needed if the patient has had a stroke.

How is the operation performed?

The operation to install a pacemaker refers to x-ray surgical methods and is performed in an x-ray operating room under local anesthesia, less often under general anesthesia.

Progress of the operation

The patient is taken on a gurney to the operating room, where local anesthesia is performed on the area of ​​skin under the left collarbone. An incision is then made into the skin and subclavian vein, and after inserting a guidewire (introducer), an electrode is passed through the vein. The electrode does not transmit x-rays, and therefore its progress into the heart cavity through the subclavian and then through the superior vena cava is well monitored using x-rays.

After the tip of the electrode is in the cavity of the right atrium, the doctor tries to find the most convenient place for it, in which the optimal modes of myocardial stimulation would be observed. To do this, the doctor records an ECG from each new point. After finding best place The location of the electrode ensures its fixation in the wall of the heart from the inside. There is passive and active fixation of the electrode. In the first case, the electrode is secured using antennae, in the second - using a corkscrew-shaped fastening, as if “screwing” into the heart muscle.

After the cardiac surgeon has managed to successfully fix the electrode, he sutures the titanium body into the thickness of the pectoral muscle on the left. Next, the wound is sutured and an aseptic dressing is applied.

In general, the entire operation takes no more than a couple of hours and does not cause significant discomfort to the patient.. After installing the pacemaker, the doctor programs the device using a programmer. All the necessary settings are set - ECG recording modes and myocardial stimulation, as well as parameters for recognizing the patient’s physical activity using a special sensor, depending on which one or another mode of pacemaker activity is carried out. An emergency mode is also configured, in which the pacemaker can work for some more time, for example, if the battery charge is running low (usually it lasts for 8-10 years).

After this, the patient remains in the hospital for several days under observation, and then is discharged for further treatment at home.

Video: Pacemaker Installation - Medical Animation

How often should I replace the stimulator?

Just a few decades ago, repeat surgery was required just two years after the first pacemaker installation. Currently The pacemaker can be replaced no earlier than 8-10 years after the first operation.

What is the cost of the operation?

The cost of the operation is calculated based on a number of conditions. This includes the price of the pacemaker, the cost of the operation itself, the length of hospital stay and rehabilitation course.

Prices for domestic and imported pacemakers vary and range from 10 to 70 thousand rubles, from 80 to 200 thousand rubles, and from 300 to 500 thousand rubles for one-, two- and three-chamber ones, respectively.

It should be noted here that domestic analogues are no worse than imported ones, especially since the probability of failure of the stimulator in all models is less than a hundredth of a percent. Therefore, the doctor will help you choose the most affordable pacemaker for each patient. There is also a system of providing high-tech types of assistance, including pacemakers, according to a quota, that is, free of charge (in the compulsory medical insurance system). In this case, the patient only needs to pay for the stay in the clinic and travel to the city where the operation is performed, if such a need arises.

Complications

Complications are quite rare and account for 6.21% in patients over 65 years of age and 4.5% in young people. These include:

Prevention of complications is a high-quality operation and adequate drug treatment in the postoperative period, as well as timely reprogramming of settings if necessary.

Lifestyle after surgery

Further lifestyle with a pacemaker can be characterized by the following components:

• Visiting a cardiac surgeon once every three months during the first year, once every six months in the second year and once a year thereafter,
• Counting your pulse, measuring blood pressure and assessing your well-being at rest and during exercise, recording the data obtained in your own diary,
• Contraindications after pacemaker installation include alcohol abuse, prolonged and exhausting physical activity, non-compliance with work and rest schedules,


• Exercise of the lungs is not prohibited physical exercise, because It is not only possible, but also necessary to train the heart muscle through exercise, if the patient does not have severe heart failure,
• The presence of an pacemaker is not a contraindication for pregnancy, but the patient must be monitored by a cardiac surgeon throughout the pregnancy, and delivery must be carried out by cesarean section as planned,
• The working capacity of patients is determined taking into account the nature of the work performed, the presence of concomitant ischemic heart disease, chronic heart failure, and the issue of loss of ability to work is decided collectively with the involvement of a cardiac surgeon, cardiologist, arrhythmologist, neurologist and other specialists,
• A patient with an pacemaker may be assigned a disability group if the working conditions are determined by a clinical expert commission to be severe or that could cause harm to the stimulator (for example, working with electric welding or electric steel-smelting machines, other sources of electromagnetic radiation).

Except general recommendations, the patient must always have a pacemaker passport (card) with him, and from the moment of surgery it is one of the patient’s main documents, because in case of emergency care The doctor should be aware of the type of pacemaker and the reason why it was placed.

Despite the fact that the stimulator is equipped with a built-in system of protection against electromagnetic radiation, which interferes with its electrical activity, the patient is recommended to remain at a distance of at least 15-30 cm from radiation sources– TV, cell phone, hair dryer, electric razor and other electrical appliances. It is better to talk on the phone using the hand on the opposite side to the stimulator.

MRI is also strictly contraindicated for persons with pacemaker, since such a strong magnetic field can damage the stimulator microcircuit. MRI can be replaced if necessary computed tomography or radiography (there is no source of magnetic radiation). For the same reason, physiotherapeutic treatment methods are strictly prohibited.

Forecast

In conclusion, I would like to note that a hundred years ago people, and especially children, often died from congenital and acquired severe heart rhythm disorders. Thanks to the achievements of modern medicine, mortality from cardiovascular diseases, including from life-threatening arrhythmias. A significant role The implantation of a pacemaker plays a role in this.

For example, the forecast for complete AV block with attacks of MES without surgical treatment is unfavorable, while after treatment life expectancy increases and its quality improves. That's why the patient should not be afraid of surgery to install a pacemaker, Moreover, the trauma and risk of complications are minimal, and the benefits of this device are immeasurably high.

sosudinfo.ru

Purpose of the device

In healthy people, contraction of the heart muscle occurs under the influence of the transmission of nerve impulses. The path runs from the sinus node in the right atrium to the interventricular septum and then by fibers diverging deeper. This ensures the correct rhythm.

The coordinated activity of the main node with the sympathetic and vagus nerves allows you to adapt the number of contractions to a specific situation: when physical work, under stress, the organs and brain need more oxygen, so the heart should beat more often; a slower rhythm is sufficient during sleep.

Arrhythmias occur due to various reasons. Electrical impulses change direction, additional foci appear, each of which “claims” to be a pacemaker.

Medicines do not always lead to successful results. There are cases when combined pathology in a person precludes the use of medications. In such a situation, installing a pacemaker comes to the rescue. He is capable of:

• “force” the heart to contract at the desired rhythm;
• suppress other sources of excitation;
• monitor a person’s own heart rhythm and intervene only in case of violations.

How does the device work?

Modern views Pacemakers can be compared to a small computer. The device weighs only 50 g. The coating is made of titanium compounds. A complex microcircuit and battery are built inside, providing autonomous power to the device. The service life of one battery is designed for 10 years. This means that the pacemaker will have to be replaced with a new one. The latest modifications of the device last from 12 to 15 years.

Durable electrodes come from the device for direct contact with the myocardium. They transmit the discharge to muscle tissue. The electrode is equipped with a special sensitive head for sufficient interaction with the heart muscle.

Pacemaker operation

To understand how a pacemaker works, imagine an ordinary battery that we often use in everyday life. We always set it depending on the charge poles. In the device, a discharge occurs only when the heart’s own contractions become rare with bradycardia or chaotic with a disturbed rhythm.

The force of the discharge imposes the necessary rhythm on the heart, which is why the device is also called an artificial pacemaker. In older models, a significant drawback was the setting of a constant number of contractions, for example, 72 per minute. Of course, this is enough for a calm, measured life, slow walking. But it is not enough in cases of acceleration of movements, if you have to go for a run, or in case of excitement.

A modern heart pacemaker “does not offend”, adapts to its needs and physiological fluctuations in contraction frequency. Conductors not only transmit impulses to the myocardium, but also collect information about the established heart rhythm. The attending physician can check the effect of the device in specific situations.

Types of devices

The need for an artificial pacemaker can be temporary or permanent. Temporary installation of a pacemaker is necessary for the duration of the patient's hospital stay to treat short-term problems:

• bradycardia after heart surgery;
• eliminating drug overdose;
• relieving an attack of paroxysmal fibrillation or ventricular fibrillation.

Pacemakers for the treatment of long-term problems with arrhythmias are produced by different companies and have their own differences. Practically, they can be divided into three types.

Single-chamber - characterized by one single electrode. It is placed in the left ventricle, but it cannot influence atrial contractions; they occur independently.

Disadvantage of the model:

• in cases where the rhythm of contractions of the ventricle and atria coincides, blood circulation inside the heart chambers is disrupted;
• not applicable for atrial arrhythmias.

Double-chamber pacemaker - equipped with two electrodes, one of them is located in the ventricle, the second in the atrium cavity. Compared to single-chamber models, it has advantages because it is able to control and coordinate both atrial and ventricular rhythm changes.

Three-chamber is the most optimal model. It has three electrodes that are implanted separately into the right chambers of the heart (atrium and ventricle) and into the left ventricle. This arrangement leads to a maximum approach to the physiological path of the excitation wave, which is accompanied by the support of the correct rhythm and necessary conditions synchronous contraction.

Why are devices coded?

For convenient use different models Without detailed descriptions of the purpose, a letter classification proposed jointly by American and British scientists is used.

• the value of the first letter determines in which parts of the heart the electrodes are implanted (A - in the atrium, V - in the ventricle, D - in both chambers);
• the second letter reflects the camera's perception of an electrical charge;
• the third is the functions of triggering, suppressing, or both;
• fourth - indicates the presence of a mechanism for adapting contractions to physical activity;
• fifth - includes special functional activity for tachyarrhythmias.

When encoding, no attention is paid to the last two letters, so you have to additionally find out the functions of the device.

Indications for artificial pacemaker implantation

Persistent heart rhythm disturbances have many causes. Most often, severe heart attacks and widespread cardiosclerosis lead to failures. These changes are especially severe in old age, when the body no longer has enough strength to restore and compensate for losses.

No less often, cardiac surgeons have to deal with dangerous attacks without a clear cause (idiopathic arrhythmias).

• confidence in the weakness of the sinus node;
• the presence of such types of arrhythmias as extrasystole, paroxysmal tachycardia, atrial fibrillation, if frequent attacks of ventricular fibrillation develop;
• complete atrioventricular block with attacks of loss of consciousness;
• the need to take drugs against the background of blockade to support myocardial contractile function in cases of heart failure.

Surgery is indicated if you can cope using medicinal methods fails. There are no contraindications for this manipulation.

How is temporary pacing performed?

There are simplified models for temporary pacing. Depending on the location of the place where the electrodes are placed, types of stimulation are distinguished:

• endocardial,
• epicardial,
• outer,
• transesophageal.

In case of external stimulation, adhesive electrodes are applied to the patient's skin. It is carried out if it is impossible to use the intracardiac method.

Intraesophageal stimulation is limited to temporary relief of supraventricular arrhythmias.

After the patient is removed from dangerous condition The electrodes are removed and the heart is allowed to operate at its own pace.

Progress of the permanent pacemaker implantation procedure

Surgery to install a pacemaker on long term performed without opening the chest. Local anesthesia is used. Using an incision in the subclavian region, the electrodes are inserted through subclavian vein into the heart chambers, then under the skin pectoral muscle hem the device itself.

The correct installation is checked using X-ray control and a cardiac monitor. In addition, the surgeon needs to make sure that the pacemaker is working and fully captures atrial impulses in the specified mode.

The pacemaker is replaced after the device’s service life has expired according to the same principle as the initial installation.

How to evaluate the correct operation of a pacemaker?

The frequency of the imposed rhythm is monitored on the monitor; it must correspond to the programmed one. All artifacts (vertical bursts) must be accompanied by ventricular complexes. Insufficient frequency is possible when the battery is discharged. Contractility The heart can be easily checked by a clear pulse in the ulnar artery.

When a natural rhythm frequency is detected that is higher than programmed, a reflex increase in the tone of the vagus nerve is used (carotid zone massage or Valsalva maneuver with straining while holding the breath).

During the operation, some actions of the medical staff are important:

• Carrying out electrocoagulation of blood vessels to stop bleeding may affect the operation of the pacemaker, therefore it is recommended to monitor the short pulse effect of the coagulator;
• anesthesiologists know a list of medications that can mask electrical impulses from the myocardium and block cardiac stimulation;
• if the patient's condition is accompanied by a violation of the concentration of potassium in the blood, the electrophysiological properties of myocardial cells are disrupted and the threshold of sensitivity to stimulation increases, this should be taken into account when selecting parameters.

How is the postoperative period going?

If the skin at the suture site is inflamed, moderate pain and fever are possible. Problems in setting up the device may be indicated by increased shortness of breath, pain in the chest, increasing weakness.

It is difficult to predict in advance how long a patient will live with the device installed. You need to use the average deadlines specified in the instructions.

What rules should patients with a pacemaker follow?

New skills and rules will help you return to a full life with a pacemaker.

1. You cannot stop treating the underlying disease; you should not forget that the pacemaker did not cure the patient, but only helped him adapt so as not to feel sick.
2. It is necessary to see a doctor quarterly; if your health worsens, urgently, you may have to change the dosage of medications.
3. You should master the method of determining and counting your pulse.
4. A person must carry a document with him stating that he has a pacemaker. This may be needed in emergency situations when you lose consciousness.
5. When driving a car, you can use seat belts; they do not harm the device.
6. If you have to fly on an airplane, it is recommended to notify airport security about the presence of an implanted stimulator; an alarm may respond to it.
7. Beware of metal detector inspections.
8. Travel enthusiasts should find out in advance about cardiology centers and clinics located nearby in case of emergency care.
9. Touching any sources of electrical current can be dangerous.

Are different types of instrumental examination dangerous?

If you need to consult a doctor of any specialty, you need to inform him about the implanted pacemaker. Such types of examinations as ultrasound and x-ray are considered safe. You can treat your teeth without the negative impact of dental technology.

• MRI (magnetic resonance imaging);
• operations using an electric scalpel;
• crushing stones into gallbladder and urinary tract;
• physiotherapeutic methods of treatment.

How do household appliances affect the artificial pacemaker?

The pacemaker models used are considered protected from the influence of any household appliances. Don't be afraid:

• televisions and audio equipment;
• radio and video equipment;
• electric shavers;
• hair dryers;
• washing machines;
• microwave ovens;
• computers;
• scanning and copying devices.

The position on application is unclear:

• cell phone and various gadgets, some consider it possible to put the telephone to the right ear;
• electric drill;
• welding machine;
• devices with an electromagnetic field.

How to organize the installation of a pacemaker for a patient?

Most patients who live with a pacemaker note a positive effect on all aspects of life, including feedback on the restoration of potency. However, these days you can only install the device one by one. It is due to the insufficient quota of the Ministry of Health for cardiology clinics, which guarantees payment at public expense.

The price includes the price of the device itself (from 10.5 thousand rubles. Russian production up to 450 thousand rubles for an imported device). It makes more sense to use more reliable technology.

Sometimes the total price does not include the cost of electrodes, but they will cost an additional 4.5 thousand rubles. up to 6 thousand rubles. It turns out that the entire operation will cost up to 500 thousand rubles. (perhaps inflation has already made adjustments).

A promising method for treating arrhythmias is in deserved demand. Financial problems limit the possibilities for its use.

Reviews

Nikolai Ivanovich, 55 years old: “After a severe heart attack, the rhythm began to change, frequent was replaced by rare, sometimes it seemed that the heart was stopping. I was sent for a consultation to the cardiac center, and the doctors suggested a pacemaker. The operation is not complicated. This is my second year living with batteries. I feel good. All restrictions can be fully met.”

Galina, 28 years old: “I’m a doctor, I look after my parents’ health as best I can. My father had a heart attack at the age of 59, which led to a complete blockade. The pulse reached 40. Against this background, swelling and shortness of breath began to appear (symptoms of heart failure). But cardiac glycosides cannot be used. They slow down the heart rate even more. First, my father was given a temporary endocardial stimulator and his heart was treated against this background. Then it was time to install a permanent device. I advise everyone not to delay.”

serdec.ru

Pacemaker: definition of the concept and how it affects the functioning of the heart

A pacemaker is an electronic device designed to monitor the patient’s rhythm and, if necessary, correct it.

In the literature and the media you can find the following synonyms: pacemaker, artificial pacemaker, pacemaker.

Consists of two parts:

• An electrode placed in the heart cavity to read and conduct electrical signals. It can withstand various shape changes inevitable due to patient movement and heart function. The electrode is in contact with the inner surface of the heart (endocardium) using a tip that clings to the internal structures of the heart (valvular chords) or is screwed into the heart muscle like a corkscrew to maintain stable conduction of impulses.
• A pacemaker housing containing a processor with a set of programs to control the device and an electric long-term battery. The electronic circuit is the commander-in-chief, determining the need to supply an electrical shock (impulse) to the heart muscle. The impulse has characteristics akin to electric current in a socket: strength, resistance, shape. In all cases, the pacemaker operates in “on demand” mode, that is, it sends an electrical signal to the heart only if it sees a need for it. The latter is determined by the installed program. Some pacemakers have a program that increases the basic rhythm depending on the intensity of physical activity (rate adaptation).

Based on the number of electrodes installed in the heart, pacemakers are divided into three categories: single-chamber (with one electrode), two-chamber (with two electrodes) and three-chamber (with three electrodes). The type of pacemaker installed is determined by the doctor taking into account the patient’s disease. The number of chambers does not determine the quality of the pacemaker.

Appearance of single- and dual-chamber pacemakers - gallery

In Russia, companies producing pacemakers are Cardioelectronics and Elestim-Cardio. There are many foreign companies supplying devices to our country: Medtronic, Boston Scientific, Sorin, Biotronic and others. If the patient has a choice, installation of an imported pacemaker is preferable.

Models from various manufacturers - photo gallery

Indications for device implantation

The main indication for installing a pacemaker is bradycardia (slow rhythm). The normal number of heartbeats is normally between 60 and 90 beats per minute.

There are two reasons for a decrease in heart rate:

• Violation of the formation of an electrical signal in the main intrinsic pacemaker (sinus node). As a result, the heart rate may decrease significantly, or long periods of time may appear between normal heartbeats when there is no signal (rhythm pauses).
• Disturbance in the conduction of impulses to the heart from the main driver to the heart muscle. This situation is called heart block.

Indication for implantation - heart block - video

Atrial fibrillation (or atrial fibrillation in other words) is an indication for installation of the device only if, against its background, the pulse is considered very rare, or if intervals of more than five seconds are recorded between individual heart contractions. The mechanism of development in this situation is heart block.

To determine the diagnosis, the doctor prescribes a daily recording of the patient’s rhythm - Holter ECG monitoring. Only after this study can the doctor recommend the installation of the device and its type.

Contraindications

Contraindications to installing a pacemaker are:

• Acute period of myocardial infarction (for heart blockades - at least 10 days)
• Acute period of cerebrovascular accident (stroke)
• Acute respiratory diseases
• Exacerbation of chronic diseases
• Inflammatory process at the site of intended installation of the device
• Deviations in laboratory indicators until the cause is clarified

Age is not a contraindication to installing a pacemaker.

Preparing for the intervention

Before giving consent to the operation, the patient, in a conversation with the doctor, needs to find out:

• what rhythm disturbance led to this situation,
• what type of device is planned to be installed,
• in what mode (around the clock or from time to time) the pacemaker will function,
• what restrictions await him subsequently.

On the eve of the intervention the following are required:

• Examination by an anesthesiologist
• Shaving the chest from the side where the device will be installed
• Cleansing enema
• Last meal and water intake the evening before surgery
• If the patient is receiving insulin or other hypoglycemic drugs, their intake is postponed until the first meal after surgery

Method of installing a pacemaker

Installation (implantation) of an electrical pacemaker in adult patients is carried out under local anesthesia (Lidocaine, Ultracaine). In children, implantation occurs under anesthesia.

The installation site for the device in adults is the area under the left collarbone. If you cannot use this access ( inflammatory process, fracture of the clavicle on the left side, the patient wishes to be left-handed) the intervention is performed on the right side. In children, the device is installed through an incision in the anterior abdominal wall.

At the main stage of the operation, an incision of about 5–6 centimeters is made, through it along the vessel (subclavian vein) under X-ray control A stimulating electrode is installed in the heart using a stylet conductor, after which a metal housing is attached to it using screws. From this moment on, the pacemaker system begins to function. Then the quality of the electrode installation is checked by testing the parameters of the pacemaker. After obtaining satisfactory results, a pocket (bed) for the pacemaker is formed in the tissues of the subclavian region. Next, the integrity of the dissected tissues is restored by applying sutures. The latter may be self-absorbing, or they may need to be removed later. Upon completion of the operation, an aseptic dressing is applied.

Rehabilitation

After installation of the device, the patient does not need to be in a intensive care unit. In the ward until the next morning, it is necessary to observe strict bed rest - do not get up, do not turn to one side, keep the hand on the side of the intervention with you, do not make sudden movements. For some time, it is necessary to keep ice at the site of pacemaker implantation to prevent bruising. Before discharge, painkillers and antibacterial drugs are prescribed.

The next day, the patient is allowed to get up, and the device’s operating parameters are adjusted a second time. One day after the operation, if there are no complications, the patient is discharged from the hospital. Before the first check of the device after discharge (usually within a month), you must lie and sleep in a position strictly on your back, do not lift anything heavier than a kilogram with your left hand, and do not throw your arm over your head. It is advisable to refrain from driving a car (without power steering).

For some time, symptoms may persist at the site where the pacemaker is installed. painful sensations, a feeling of “pulsating”, which then gradually disappear as the patient gets used to the artificial rhythm.

What complications may occur after the intervention?

Complications of pacemaker implantation include:

• Blood loss
• Bruising at the site where the device was installed
• Sudden shortness of breath, weakness, sharp deterioration in condition due to a lung injury in the subclavian region (pneumothorax)
• Displacement (dislocation) of installed electrodes and, as a consequence, disruption of the functioning mode of the pacemaker
• Inflammation at the surgical site
• Formation of a tissue defect over the installed device (bedsore of the pacemaker bed)

After discharge from the hospital, the doctor will determine the frequency with which the patient needs to appear to correct the stimulation parameters.

The latter occurs without anesthesia and incisions by attaching a special reading device to the device - a programmer, which allows the doctor to change the set parameters if necessary. The reasons for an unscheduled visit to a doctor are:

• Episodes of loss of consciousness, including during stereotypical movements (raising an arm, turning the head)
• The appearance of a rare pulse (less than the minimum set frequency of the device)
• Twitching of the muscles of the stimulator bed with a frequency programmed in the pacemaker memory (cause - violation of the electrode insulation)
• Impact at the location where the device is installed (fall, deployment of airbags in a car)
• Electric shock

The pacemaker is designed solely to correct the patient's rhythm. The functioning of the device in the body does not in any way affect the level of blood pressure and the frequency of arrhythmia attacks, which the patient may have had previously or appeared after installation.

If the parameters are satisfactory, after the first check the patient is allowed to sleep in any position, lift up to five kilograms with his left hand, and drive a car. The possibility of returning to work and the timing are determined by a medical commission.

After installing the device in your home, you can use all appliances (working!): washing machine, dishwasher, microwave oven, TV, cell phone and radiotelephone, electric toothbrush, electric razor, hair clipper, hair dryer and others.

When going through metal detectors in stores, show your implanted device patient card. It is not recommended to go through pre-flight controls at the airport (present your patient card).

All sports are allowed, with the exception of those involving heavy lifting; carefully team games(it is necessary to protect the pacemaker from direct impact).

Drinking alcohol and coughing do not affect the functioning of the device.

The following medical procedures are allowed:

• Fluorography
• Radiography
• CT scan
• Dental procedures
• Ultrasonography
• Electrocardiography
• Massage (except for the ECS bed), including pneumomassage
• In Vitro Fertilization
• Vaginal birth
• Hirudotherapy (placement of leeches)

The following medical procedures are prohibited:

• Magnetic resonance imaging
• External lithotripsy
• Electrocoagulation
• Diathermy
• Electrophoresis
• Magnetotherapy (including the Almag apparatus)
• Electromyostimulation

It must be remembered that the pacemaker will now be present in the patient’s body for life. Over time, the battery capacity of the pacemaker decreases, so you need to come for a check at the time agreed with your doctor. On average, the period of operation of a pacemaker ranges from 5 to 15 years (this indicator is influenced by the type of disease, the percentage of its rhythm and the rhythm of the pacemaker, as well as the installed settings). If the remaining battery capacity is small, an operation is provided to replace the pacemaker - through an incision, replacing one device with another, if necessary, placing new electrodes in the heart.

A pacemaker, unfortunately, is not a panacea eternal life. The life expectancy of patients with an implanted pacemaker is the same as patients who have not undergone such intervention.

Heart pacemaker: patient reviews

I have a lot of friends who live with stimulants, and so far, ugh, there are some who have been wearing it for 10 years. I don’t know the exact specifics, but I know that a friend has been wearing it for 5 years and doesn’t feel it. Also, when her blood pressure rises, they give her IVs and treat her like everyone else. She says that sometimes even with the stimulator she has attacks of arrhythmia, but they are not as severe as they were before. In general, she is happy. You have to live somehow.

Sima

2.5 months ago I was fitted with a dual-chamber EX-454, two ELBI electrodes - atrial and ventricular. My shortness of breath became less and it became a little easier to breathe. But the ventricular electrode creates discomfort. I constantly feel its blows (or contractions) and very strongly, especially if I lie on my left side, even when I sit, I feel it. Very unpleasant. This is already the fourth EX. The previous ones were single-chamber. I am 65 years old.

Guzhova

http://forumjizni.ru/showthread.php?t=9816

My mother had a pacemaker installed a week ago. Before that she had high pressure, but which she has learned to cope with. And arrhythmia - attacks when it gets out of control - have become more and more frequent. Once a week, then every day. I called an ambulance. In January, she already spent time in intensive care, then in the hospital, when the ambulance was unable to relieve the attack. And now again. They kept her in intensive care for a week and a half to install a pacemaker (I doubted its necessity and still doubt it now, because she had bradycardia occasionally, but attacks of arrhythmia are the main problem).

Wild Kisya Hys-Khys

http://forum.materinstvo.ru/index.php?showtopic=2020461

Pacemaker implantation is the only effective method of radical treatment of bradyarrhythmias. The pacemaker allows the patient to maintain quality of life and its normal duration.

treatment-simptomy.ru

Natural pacemaker

Anatomically, the pacemaker of the heart is located in the right atrium where the superior vena cava flows into it. This piece of muscle tissue is called the sinus node. It is responsible for the generation of impulses that form a wave of excitation, which travels further through all parts of the heart and regulates its normal functioning. This excitation and transmission system ensures the rhythm and synchronization of the work of all chambers - both the atria and the ventricles.

Nature has provided several pacemakers in the heart. The main one is the sinus node (first order driver). It provides a normal heart rate - 60 - 90 per minute. In a pathological condition, when the sinus node fails, the second-order pacemaker, the atrioventricular (atrioventricular) node, is activated. It generates a smaller number of contractions - from 40 to 50. If this node also refuses to produce impulses, the conductive bundle of His takes over this function. Normally, it is the conductor of impulses sent by the sinus node. The number of heart contractions produced by the His bundle as a pacemaker does not exceed 30–40 per minute.

Driver migration and heart block

Sometimes the heart begins to beat unevenly - the rhythm slows down or speeds up, it “misses” a beat or, conversely, gives out an “extra” beat. Such a malfunction in its work is called arrhythmia. This means that the sequence of impulse transmission has been disrupted. The transition of the sinus driver function to the atrioventricular driver is called migration. Arising first in the second-order pacemaker, it suppresses the wave from the sinus node. In this case, the synchronicity of contraction of all chambers of the heart and the passage of the impulse from the main generating beam to the conductive (Gis) beam are disrupted. Doctors call this condition heart block.

Uneven contraction of the atria and ventricles disrupts the normal flow of oxygenated blood and its flow to all tissues and organs. First of all, the brain “starves”. With a partial blockade, a person may not feel specific symptoms. Arrhythmia is accompanied by symptoms that can be attributed to other diseases:

• general malaise and decreased performance;
• dizziness;
• increased blood pressure;
• feeling of interruptions and pain in the heart.

One of the causes of heartbeat disturbances is AV block. It has three degrees:

Degree	Violations
1st degree	The conduction of impulses from the sinus node through the atrioventricular node is disrupted. The interval of its passage increases
2nd degree	Type 1 – the interval of impulse passage through the atrioventricular node increases with periodic loss of ventricular contractions;
	Type 2 – the interval does not shorten, but ventricular contractions are lost;
	Impulse pathology increases
3rd degree	The transmission of impulses through the atrioventricular node stops, spontaneous contraction of the ventricles begins

Bradysystole is especially dangerous. This is a condition where the atria contract normal rhythm, and the ventricles are in slow motion. The person feels shortness of breath, severe dizziness, and darkening of the eyes. Objectively, this occurs due to a sharp deterioration in blood circulation and cerebral ischemia, especially when the heart rate drops to 15 beats per minute. Possible loss of consciousness, a feeling of intense heat in the head and sudden paleness of the skin. Among all heart diseases that lead to death, a tenth of them are arrhythmias.

Indications for installation of a pacemaker

An artificial heart pacemaker (APM) can return a patient to normal life with heart block and other rhythm disturbances. Pacemakers work by being able to electronically detect changes in the heart and adjust its rhythm if necessary. Indications for installation:

• pathological bradycardia (slow heartbeat);
• heart rate discrepancy physiological needs during physical activity;
• ventricular tachycardia (ventricular extrasystole);
• permanent or transient (transient) AB heart block of 2 and 3 degrees after myocardial infarction;
• atrial fibrillation (fibrillation and flutter).

Contraindications for surgery are acute infectious diseases and mental disorders a patient with whom productive contact to set up the device is impossible.

Types of artificial pacemaker

The type of artificial pacemaker (pacemaker) depends on the problem that needs to be solved:

• cardioverter - a defibrillator designed to correct the rhythm during ventricular paroxysmal tachycardia (rapid heart rate);
• An electrical pacemaker (pacemaker) normalizes a slow heartbeat by stimulating the sinus node.

Electrical pulse therapy, which includes the use of cardioverters - defibrillators, has proven itself as an effective means of correcting cardiac arrhythmias. The essence of the technique is to electrically “reboot” the heart. A short-term current is applied to the myocardium, which depolarizes active muscle cells and forces them to work in the correct mode.

Operating principle of IVR

The main part of the ECS is the microcircuit. In fact, it continuously takes an electrocardiogram, monitoring the heart rhythm. The device is equipped with a battery, which is used to influence the myocardium. The proper functioning of the heart is stimulated by electrodes that are implanted into the heart muscle. Setting up and monitoring the operation of the pacemaker is carried out through a programmer - a computer located in the clinic where the pacemaker was implanted.

How is the operation performed?

Implantation is carried out under local anesthesia and under X-ray control. The doctor makes an incision and inserts an electrode through the subclavian vein into the right atrium. Using an electrocardiogram, he empirically selects the best position of the electrode and secures it in the heart muscle. The ECS body is sewn into the thickness of the left pectoral muscle.

The pacemaker is programmed using the following parameters:

• ECG recording mode;
• stimulation mode;
• recognition of the degree of physical activity;
• operation in emergency mode (for example, when the battery is prematurely discharged).

After the operation, the patient is under medical supervision for several more days. The device's battery is designed to last uninterrupted operation within 8 – 10 years.

Possible complications

Complications are rare and may include the following:

• wound infection with suppuration and fistula formation;
• displacement of the electrode in the heart cavity;
• fluid accumulation in the pericardium and bleeding;
• exposure to current (stimulation) on the pectoral muscles and diaphragm;
• depletion of the stimulant and loss of its sensitivity;
• electrode damage.

Complications can be prevented by observing all requirements for installing the device, carrying out adequate drug therapy after surgery and promptly reprogramming the pacemaker.

How is your lifestyle changing?

The pacemaker does not require a passive lifestyle. On the contrary, moderate physical activity is necessary to train the heart muscle. Pregnancy is not contraindicated, but always with constant visits to a cardiologist. Not recommended:

• abuse alcohol;
• engage in heavy physical work.

Exposure to electromagnetic radiation should be avoided (located at a distance of 40–50 cm from the TV, computer and other devices).

Necessary:

• visit a cardiologist regularly;
• keep a diary in which the patient records blood pressure and pulse, as well as general well-being;
• Always have your passport and a special EKS card with you.

Patients with a pacemaker are contraindicated for MRI testing.

Today, pacemakers save thousands of lives. The likelihood of complications occurring is extremely small compared to the benefits this device brings.

More than three hundred thousand electrical pacemakers (Pacemakers) are installed annually around the world. permanent basis, since patients with some severe heart lesions require an artificial pacemaker.

Types of pacemakers

A pacemaker is an electronic device that generates electrical impulses using a special circuit. In addition to the circuit, it contains a battery that supplies energy to the device and thin wires-electrodes.

There are different types of heart pacemakers:

• single-chamber, which are capable of stimulating only one chamber - the ventricle or atrium;
• dual-chamber, which can stimulate two cardiac chambers: both the ventricle and the atrium;
• Three-chamber pacemakers are required for patients with heart failure, as well as in the presence of ventricular fibrillation, ventricular tachycardia and other life-threatening types of arrhythmias.

Indications for installation of a pacemaker

Are you still wondering what a pacemaker is for? The answer is simple - an electrical pacemaker is designed to impose the correct sinus rhythm on the heart. In what cases is a pacemaker installed? To set it, there can be both relative and absolute indications.

Absolute indications for a pacemaker

Absolute indications are:

• bradycardia with pronounced clinical symptoms - dizziness, syncope, Morgagni-Adams-Stokes syndrome (MAS);
• episodes of asystole lasting more than three seconds, recorded on the ECG;
• if during physical activity the heart rate is recorded below 40 per minute;
• when persistent atrioventricular block of the second or third degree is combined with two-bundle or three-bundle blockades;
• if the same blockade occurs after myocardial infarction and manifests itself clinically.

In cases of absolute indication for the installation of a pacemaker, the operation can be performed either planned, after examinations and preparation, or urgently. With absolute indications, contraindications to the installation of pacemakers are not taken into account.

Relative indications for pacemaker

The relative indications for a permanently implanted pacemaker are as follows:

• if third-degree atrioventricular block occurs at any anatomical site with a heart rate under a load of more than 40 beats, which is not clinically manifested;
• the presence of atrioventricular block of the second type and second degree without clinical manifestations;
• syncope in patients against the background of two- and three-fascicular blockades, not accompanied by ventricular tachycardia or transverse block, while it is not possible to establish other causes of syncope.

If a patient has only relative indications for undergoing surgery to install a heart pacemaker, the decision to implant it is made individually, taking into account the patient’s age, physical activity, accompanying illnesses and other factors.

When is the installation of a pacemaker not justified?

In fact, a pacemaker has no contraindications for its installation, except in the case of its unjustified implantation.

Such insufficient grounds for implantation are:

• first degree atrioventricular block without clinical manifestations;
• proximal atrioventricular block of the first type of the second degree, without clinical manifestations;
• atrioventricular block that can regress (for example, caused by medication).

Now let's talk about how a pacemaker is installed. If you watch a video of how a pacemaker is installed, you will notice that a cardiac surgeon performs it under X-ray control, and total time The procedure varies depending on the type of implanted device:

• a single-chamber pacemaker will require half an hour;
• for a two-chamber pacemaker – 1 hour;
• A three-chamber pacemaker requires 2.5 hours to install.

Typically, surgery to install a pacemaker occurs under local anesthesia.

The operation to implant an pacemaker consists of the following steps:

1. Preparing for surgery. This includes processing surgical field and local anesthesia. An anesthetic drug (novocaine, trimecaine, lidocaine) is injected into skin and underlying tissues.
2. Installation of electrodes. The surgeon makes a small incision in the subclavian region. Next, the electrodes under X-ray control are inserted sequentially through the subclavian vein into the desired cardiac chamber.
3. Implantation of the pacemaker housing. The device body is implanted under the collarbone, and it can be installed subcutaneously or deepened under the pectoral muscle.

In our country, the device is more often implanted in right-handed people on the left, and in left-handed people on the right, which makes it easier for them to use the device.

1. The electrodes are connected to the already implanted device.
2. Device programming. It is produced individually to suit the patient’s needs, taking into account the clinical situation and the capabilities of the device (which also determine the cost of the pacemaker). In modern devices, the doctor can set the basic heart rate, both for the state of physical activity and for rest.

Essentially, this is all the basic information about how a pacemaker is installed.

Complications after pacemaker installation

It is worth knowing that complications after installing a pacemaker occur in no more than 3-5% of cases, so you should not be afraid of this operation.

Early postoperative complications:

• leakage pleural cavity(pneumothorax);
• thromboembolism;
• bleeding;
• violation of insulation, displacement, fracture of the electrode;
• infection of the surgical wound area.

Long-term complications:

• EX syndrome - shortness of breath, dizziness, decreased blood pressure, episodic loss of consciousness;
• pacemaker-induced tachycardia;
• premature failures in the ECS.

The operation to insert a pacemaker must be performed by an experienced surgeon under X-ray control, which helps prevent most of the complications that arise during surgery. early stage. And in the future, the patient must undergo regular examinations and be registered with a dispensary.

If there are complaints about deterioration in health, the patient should immediately consult with the attending physician.

What can and cannot be done if you have a pacemaker?

Living with a pacemaker has limitations regarding physical activity and electromagnetic factors that may prevent the device from working correctly. Before any examination or course of treatment, it is necessary to warn doctors about the presence of an pacemaker.

Living with a heart pacemaker imposes the following restrictions on a person:

• undergo an MRI;
• engage in hazardous sports;
• climb high-voltage power lines;
• approach transformer booths;
• put a mobile phone in your breast pocket;
• stay close to metal detectors for a long time;
• undergo shock wave lithotripsy without preliminary adjustment of the pacemaker or do it during surgery electrocoagulation of tissues.

Cost of installing a pacemaker

Basically, since pacemaker implantation is paid for by the compulsory medical insurance fund, the cost of installing a pacemaker is usually zero.

But sometimes patients pay for it themselves and Additional services(this applies to foreigners and persons who do not have compulsory medical insurance).

The following prices apply in Russia:

• implantation of a pacemaker – from 100 to 650 thousand rubles;
• implantation of electrodes – minimum 2000 rubles;
• surgical manipulations – from 7,500 rubles;
• Staying in the ward costs at least 2,000 rubles per day.

The overall cost is most influenced by the ECS model and the prices of the selected clinic. For example, in a provincial cardiology center, simple implantation of an outdated domestic pacemaker model can cost at least 25,000 rubles. In large vascular clinics that use modern imported devices and provide additional services, the cost jumps to 300 thousand rubles.

How to behave after installing a pacemaker?

First postoperative week

• The postoperative wound should be kept clean and dry according to the recommendations of the medical staff.
• If the early postoperative period is favorable, five days after surgery it is already permissible to take a shower, and a week later most patients return to their usual work schedule.
• To prevent the seams from coming apart, you should not lift more than 5 kg for the first time.
• You can't do heavy homework, and when doing lighter work, you need to listen to how you feel and immediately postpone work if you experience discomfort. You can't force yourself.

One month after surgery

• Exercising after having a pacemaker installed is not only useful, but also necessary. Long walks are beneficial. But tennis, swimming pool and other strenuous sports will have to be postponed for a while. Over time, the doctor monitoring the patient's health may remove some restrictions regarding sports.
• You need to visit the doctor according to plan: after 3 months - the first examination, after six months - the second, and then every six months or a year.

If a person feels discomfort or anxiety about the operation of the pacemaker, then they should consult a doctor immediately.

Life after pacemaker implantation

• Electrical devices. Although ECS are equipped with protection from interference from others electrical appliances However, strong electric fields should still be avoided. The use of almost all household appliances is allowed: TV, radio, refrigerator, tape recorder, microwave oven, computer, electric razor, hair dryer, washing machine. To avoid interference, you should not approach the pacemaker implantation site closer than 10 cm to an electrical appliance, lean against the front wall of the microwave (and generally avoid it) or the screen of a working TV. You should stay away from welding equipment, electric steelmaking furnaces, and high-voltage power lines. It is not advisable to go through control turnstiles in shops, airports, and museums. In this case, upon discharge from the hospital, the patient is given a device passport and an owner’s card, which must be presented during the search, after which it can be replaced by a personal search. The KS is also not afraid of most office equipment. It is advisable to develop the habit of grasping appliance plugs and other voltage sources with the hand further away from the pacemaker.
• Mobile phone. Long conversations on it are undesirable, and you need to hold the receiver 30 cm or more from the CS. When talking, hold the tube to the ear on the opposite side of the implantation site. Do not carry the handset in your breast pocket or around your neck.
• Sport. It is prohibited to engage in contact and traumatic sports, that is, team games, martial arts, since any blow to abdominal cavity or chest may damage the device. For the same reason, shooting with a gun is not recommended. With a pacemaker you can return to walking, swimming and such physical exercises that allow constant monitoring of well-being and allow you to comply with safety rules.

The area of ​​the body where the pacemaker was implanted should not be exposed to direct sunlight. It should be kept covered with some kind of cloth at all times. Also, avoid swimming in cold water. It is especially important for car enthusiasts to remember that they should not touch live wires while repairing a car or replacing a battery.

Validity period and how long do people live with a pacemaker?

On average, the lifespan of a pacemaker is determined by the capacity of the battery, designed for 7-10 years of operation. When the battery life is approaching, the device will give a signal during the next scheduled examination. After this, you should replace the battery with a new one. Therefore, the question of how long people can live with a pacemaker also depends on the regularity of visiting the doctor. There is an opinion that, being a foreign body, the CS can harm a person. This is not at all true, despite the fact that often there is no alternative to installing it. In order to continue a fully fulfilling life, you have to put up with only minor restrictions that are worth it. In addition, it can be installed completely free of charge.

You can often hear the question of how long people can live with a pacemaker, especially from those for whom such surgery is recommended. Medical practice shows that people with an implanted pacemaker, subject to all doctor’s recommendations, live no less than other people.

In other words, having a pacemaker can only prolong life, not make it shorter.

Have you already had a pacemaker installed? Or do you still have to undergo this operation? Tell your story and feelings in the comments, share your experience with others.

For artificial pacemaker implantation (IVR) the possibility of fluoroscopy, ECG monitoring and conducting cardiopulmonary resuscitation. The procedure is usually performed under local anesthesia and takes less than 45 minutes. Sedation is often used. Strict adherence to asepsis rules is mandatory. Careful hand cleaning is necessary, as surgical gloves do not provide a reliable barrier to infection.

Installation of a pacemaker through a subclavian approach

This access is widely used. Electrodes artificial pacemaker (IVR) are introduced through the subclavian vein by puncture and connected to a generator, which is implanted in a subcutaneous pocket formed above the pectoralis major muscle.

Commonly used left subclavian vein. However, in some cases there is a functioning left superior vena cava that drains directly into the coronary sinus, through which in such cases the atrial and/or ventricular lead must be inserted. This is usually doable, but technically difficult.

Functioning left superior vena cava most often occurs in individuals with congenital heart defects, especially atrial septal defect. If the patient is known to have a congenital heart defect, the right subclavian approach is preferable.

Incision skin is performed 2 cm below the border of the inner and middle thirds of the clavicle and expands in the inferolateral direction to approximately 6 cm. By blunt tissue detachment, a subcutaneous pocket is formed, sufficient for implantation of the generator. It is much easier to puncture the subclavian vein if it is dilated: this is facilitated by placing the bed in a position with the head of the bed slightly lowered.

As alternatives the patient should slightly raise his legs. Dehydration leads to a significant decrease in venous pressure and, therefore, makes puncture more difficult. Dehydration should be avoided or corrected in advance.

The needle is inserted into a point located immediately under the lower edge of the collarbone on the border of its inner and middle thirds towards the sternoclavicular joint so that it passes behind the posterior surface of the clavicle. When a vein is punctured, venous blood is easily aspirated with a syringe. The appearance of only a thin stream of blood in the syringe suggests that the tip of the needle is not in a vein.

Air aspiration or appearance bright pulsating stream of blood indicates puncture of the pleura or subclavian artery, respectively. If the patient has a “deep” chest and especially if the clavicles are curved anteriorly, the needle should be inserted laterally and directed slightly posteriorly.

Then it is produced vein cannulation. To do this, a flexible guide wire with a J-shaped end is inserted through the needle. If there is a feeling of resistance as it advances, this means that the guidewire is not in the vein. The guidewire is inserted into the superior vena cava and its position is monitored using fluoroscopy. (If the guidewire is visualized in the center of the chest, this may indicate that the subclavian artery, rather than a vein, was punctured and the tip of the guidewire is in the aorta.)

Then the needle is removed, and into the vein an introducer is installed on the guidewire with a vascular dilator inserted into it. After this, the dilator and guidewire are removed, and the electrode is inserted through the introducer.

If you plan to install second or third electrode, then the appropriate number of conductors is inserted into the vein through the introducer. Then the introducer is removed and a separate introducer with a dilator is sequentially introduced through each of the conductors. Peel-away introducers are used, the removal of which is not hampered by the connector located at the proximal end of the electrode.

Electrodes inserted into the right atrial appendage (RA), into the area of ​​the outflow tract and the apex of the right ventricle (RV)
(so-called bifocal stimulation) through the persistent left superior vena cava.

Installation of a pacemaker through the lateral saphenous vein of the arm

An alternative to subclavian vein puncture is the dissection of the lateral saphenous vein of the arm in the deltopectoral groove. This approach avoids the risks associated with puncture of the subclavian vein, however, sometimes this vein is not large enough, and therefore, in some cases, it becomes difficult to pass the electrode from the lateral saphenous vein of the arm to the subclavian vein.

However, the use of a conductor with a hydrophilic coated, through which the introducer is then inserted, greatly facilitates overcoming the bends along the lateral saphenous vein of the arm.

Ventricular lead placement

To provide manipulation a very flexible electrode for continuous stimulation; a guide stylet is inserted into its internal lumen. Forming a slight bend in the distal part of the stylet or slightly pulling it out of the electrode facilitates installation.

Electrode carried into the right atrium (RA). It is then sometimes immediately able to move it through the tricuspid valve directly into the right ventricle (RV). However, more often for this it is necessary to first form a loop in the atrium, for which the tip of the electrode should be rested against the wall of the atrium, and then move the electrode slightly forward. After this, by rotating the electrode around its axis, you can bring its tip closer to the tricuspid valve. Gently pulling the electrode back allows its tip to “fall” through the valve into the ventricle.

Walkthrough electrode through the valve always provokes ventricular ectopic activity. If ventricular ectopic activity does not occur, then the tricuspid valve is likely not crossed and the lead is likely located in the coronary sinus.

Finding electrode in the ventricle can be confirmed by advancing it into the pulmonary artery. Using rotational and translational movements, the tip of the electrode, already inserted into the right ventricle (RV), is installed in the area of ​​its apex or outflow tract. It is necessary to ensure the stability of the electrode position by confirming that there is no significant displacement of its tip and that stimulation is stable during deep breathing and coughing.

An additional technique to evaluate electrode position stability, is an attempt to partially remove it (so that its play is minimal) and then an attempt to move it forward excessively (so that its play is excessive).

As soon as electrode position considered satisfactory both from the point of view of position stability and taking into account the measurement of parameters, it is important to fix it with a short coupling, placing it near the point of entry into the vein and suturing it to the underlying muscle using a non-absorbable suture material. It is important to ensure that the electrode inside the coupling is securely fixed. Otherwise, it may shift.

Installation of a transvenous pacemaker lead ():
a, b - a loop is formed in the right atrium (RA);
c - the loop moves towards the tricuspid valve (dotted oval);
d - you can make sure that the electrode is really in the pancreas by moving it into the pulmonary artery; f - then the electrode is installed in the area of ​​the apex of the right ventricle (RV);
f - characteristic picture of the location of the electrode in the coronary sinus.

Atrial Lead Installation

Usual place atrial stimulation is the right atrial appendage (RA). If necessary, stimulation can be performed using a “screw-in” electrode located in the interatrial septum or in the free wall of the RA. To install the electrode in the RA appendage, you need to use a straight stylet to advance its tip into the tricuspid valve area. Then the straight stylet is removed, and the electrode is installed in the ear using another stylet, the distal 5 cm of which have a J-shaped bend.

If the electrode is slightly pulled away from the tricuspid valve, its tip “falls” into the atrial appendage.

The correctness of the position is confirmed by the fact that when each atrial systole the tip of the electrode moves from side to side. During fluoroscopy in lateral projection, the electrode is directed forward. The stability of the electrode position must be confirmed by rotating it 45° in both directions. In this case, the tip should not turn. It is important to correctly adjust the electrode play. During inspiration, the angle between the two J-arms should not exceed 80°.

Forming a pocket for a pacemaker

It may seem that creating a pocket for pacemaker is the least the hard part implantation procedures. However, if it is not formed correctly, wound complications are likely to develop. They often develop several months after implantation.

Subcutaneous pocket for pacemaker usually formed by blunt tissue detachment. It is necessary to thoroughly infiltrate the tissues local anesthetic. Even so, some patients experience discomfort during the 1-2 minutes it takes to create the pocket. It is important that the wound is deep enough to place the stimulator on the surface of the pectoralis muscle.

A common mistake is pocket formation close to the collarbone, where the subcutaneous tissue is poorly developed. This increases the risk of skin ulceration in the IVR area. The pocket must be formed lower, which will allow it to be covered with a thicker layer of fabric.

Over the past decades, medicine has reached unimaginable heights. This is especially evident in cardiology and cardiac surgery. A hundred years ago, cardiologists could not even imagine that one day they would be able to not only literally “look” into the heart and see its work from the inside, but also make the heart work in conditions of seemingly incurable diseases, in particular serious heart rhythm disturbances. In such cases, artificial pacemakers are used to save the patient's life.

What types of pacemakers are there?

An artificial cardiac pacemaker (electrical pacemaker, pacemaker) is a complex electronic device equipped with a microcircuit that allows it to perceive changes in the activity of the heart muscle and correct myocardial contractions if necessary. Such a device consists of the following parts:

A titanium case containing: a battery that generates energy to create electrical impulses, a microcircuit that allows receiving and interpreting electrical potentials cardiac muscle, or, in other words, an electrocardiogram, a connector block that connects the body and electrodes. Electrodes inserted directly into the heart muscle, reading information about the electrical activity of the heart and carrying electrical charges that stimulate proper contractions of the heart muscle. A programmer is a computer that is located in medical institution, where the pacemaker was implanted. With its help, you can install and, if necessary, change the settings of the pacemaker.

Location of electrodes in the heart

An electrocardiostimulator (ECS) records and interprets a cardiogram, based on which it performs its functions.

Thus, during paroxysm of ventricular tachycardia (frequent rhythm), the cardioverter-defibrillator performs an electrical “reboot” of the heart, followed by imposing the correct rhythm through electrical stimulation of the myocardium.

Another type of pacemaker is an artificial pacemaker (pacemaker), which stimulates myocardial contractions during dangerous bradycardia (slow rhythm), when rare heart contractions do not allow adequate release of blood into the vessels.

In addition to this division, the pacemaker can be one-, two- or three-chamber, consisting respectively of one, two or three electrodes, connected to one or more chambers of the heart - to the atria or ventricles. The best pacemaker today is a two-chamber or three-chamber device.

In any case, the main function of the pacemaker is to identify, interpret rhythm disturbances that can lead to cardiac arrest, and correct them in a timely manner through myocardial stimulation.

Indications for surgery

The main indication for cardiac pacing is the presence of arrhythmia in the patient, which occurs as bradycardia or tachycardia.

To bradyarrhythmias, requiring the installation of an artificial pacemaker include:

Sick sinus syndrome, manifested by a decrease in heart rate of less than 40 per minute, and including complete sinoatrial block, sinus bradycardia, as well as brady-tachycardia syndrome (episodes of sharp bradycardia, suddenly followed by attacks of paroxysmal tachycardia), Atrioventricular block of the II and III degrees (complete block), Carotid sinus syndrome, manifested by a sharp slowing of the pulse, dizziness and possible loss of consciousness when the carotid sinus, located in the carotid artery superficially under the skin of the neck, is irritated; irritation can be caused by a narrow collar, a tight tie or too active turns of the head. Any type of bradycardia accompanied by Morgagni-Edams-Stokes (MES) attacks - attacks of loss of consciousness and/or convulsions that occur as a result of short-term asystole (cardiac arrest) and can lead to lethal outcome.

To tachyarrhythmias, capable of causing severe complications and requiring artificial cardiac pacing include:

Paroxysmal ventricular tachycardia, Atrial fibrillation (atrial fibrillation and atrial flutter), Frequent ventricular extrasystole, which has a high risk of developing into ventricular fibrillation and flutter.

Video: about installing a pacemaker for bradycardia, the program “About the Most Important Thing”

Contraindications for surgery

There are no contraindications for implantation of a pacemaker for health reasons. The operation can be performed even in patients with acute myocardial infarction, if the latter is complicated by complete AV block or other severe rhythm disturbances.

However, if at the moment the patient has no vital indications, and he can live without a pacemaker for some more time, Surgery may be delayed if:

The patient has a fever or acute infectious diseases, exacerbation of chronic diseases of internal organs (bronchial asthma, stomach ulcers, etc.), mental illness with the patient’s inaccessibility to productive contact.

In any case, indications and contraindications are determined strictly individually for each individual patient, and there are no clear criteria.

Preparation and tests before surgery

The need for cardiac surgery can be emergency, when the patient’s life is impossible without an operation to install a pacemaker, or planned, when his heart can work independently for several months even with rhythm disturbances. In the latter case, the operation is carried out as planned, and before performing it it is advisable to conduct a full examination of the patient.

The list of required tests may vary in different clinics. Basically the following must be done:

ECG, including daily monitoring ECG and Holter blood pressure, which allows you to register even very rare but significant rhythm disturbances over a period of one to three days, EchoCG (ultrasound of the heart), Blood test for thyroid hormones, Examination by a cardiologist or arrhythmologist, Clinical blood tests - general, biochemical , blood test for coagulation, Blood test for HIV, syphilis and hepatitis B and C, General urine test, stool test for worm eggs, FGDS to exclude gastric ulcer - if it is present, treatment by a gastroenterologist or therapist is mandatory, since after surgery they are prescribed drugs that thin the blood, but have a destructive effect on the gastric mucosa, which can lead to gastric bleeding, Consultation with an ENT doctor and dentist (to exclude foci of chronic infection that can have a negative effect on the heart, if detected, foci should be promptly sanitized and treated ), Consultations with specialized specialists if there are chronic diseases (neurologist, endocrinologist, nephrologist, etc.). In some cases, an MRI of the brain may be needed if the patient has had a stroke.

How is the operation performed?

The operation to install a pacemaker refers to x-ray surgical methods and is performed in an x-ray operating room under local anesthesia, less often under general anesthesia.

Progress of the operation

The patient is taken on a gurney to the operating room, where local anesthesia is performed on the area of ​​skin under the left collarbone. An incision is then made into the skin and subclavian vein, and after inserting a guidewire (introducer), an electrode is passed through the vein. The electrode does not transmit x-rays, and therefore its progress into the heart cavity through the subclavian and then through the superior vena cava is well monitored using x-rays.

After the tip of the electrode is in the cavity of the right atrium, the doctor tries to find the most convenient place for it, in which the optimal modes of myocardial stimulation would be observed. To do this, the doctor records an ECG from each new point. After finding the best location for the electrode, it is fixed in the wall of the heart from the inside. There is passive and active fixation of the electrode. In the first case, the electrode is secured using antennae, in the second - using a corkscrew-shaped fastening, as if “screwing” into the heart muscle.

After the cardiac surgeon has managed to successfully fix the electrode, he sutures the titanium body into the thickness of the pectoral muscle on the left. Next, the wound is sutured and an aseptic dressing is applied.

In general, the entire operation takes no more than a couple of hours and does not cause significant discomfort to the patient.. After installing the pacemaker, the doctor programs the device using a programmer. All the necessary settings are set - ECG recording modes and myocardial stimulation, as well as parameters for recognizing the patient’s physical activity using a special sensor, depending on which one or another mode of pacemaker activity is carried out. An emergency mode is also configured, in which the pacemaker can work for some more time, for example, if the battery charge is running low (usually it lasts for 8-10 years).

After this, the patient remains in the hospital for several days under observation, and then is discharged for further treatment at home.

Video: Pacemaker Installation - Medical Animation

How often should I replace the stimulator?

Just a few decades ago, repeat surgery was required just two years after the first pacemaker installation. Currently The pacemaker can be replaced no earlier than 8-10 years after the first operation.

What is the cost of the operation?

The cost of the operation is calculated based on a number of conditions. This includes the price of the pacemaker, the cost of the operation itself, the length of hospital stay and rehabilitation course.

Prices for domestic and imported pacemakers vary and range from 10 to 70 thousand rubles, from 80 to 200 thousand rubles, and from 300 to 500 thousand rubles for one-, two- and three-chamber ones, respectively.

It should be noted here that domestic analogues are no worse than imported ones, especially since the probability of failure of the stimulator in all models is less than a hundredth of a percent. Therefore, the doctor will help you choose the most affordable pacemaker for each patient. There is also a system of providing high-tech types of assistance, including pacemakers, according to a quota, that is, free of charge (in the compulsory medical insurance system). In this case, the patient only needs to pay for the stay in the clinic and travel to the city where the operation is performed, if such a need arises.

Complications

Complications are quite rare and account for 6.21% in patients over 65 years of age and 4.5% in young people. These include:

Infectious complications - wound suppuration, formation of a purulent fistula, sepsis (blood poisoning), Dislocation (displacement of electrodes in the heart cavity), Bleeding and cardiac tamponade (accumulation of blood in the pericardial cavity, or pericardial sac), Stimulation of the muscles of the chest and diaphragm, Loss of detector ( perceptive) function of the stimulator, leading to disruption of myocardial stimulation modes, Early depletion of the stimulator, Electrode fracture.

Prevention of complications is a high-quality operation and adequate drug treatment in the postoperative period, as well as timely reprogramming of settings if necessary.

Lifestyle after surgery

Further lifestyle with a pacemaker can be characterized by the following components:

Visiting a cardiac surgeon once every three months during the first year, once every six months in the second year and once a year thereafter, counting your pulse, measuring blood pressure and assessing your well-being at rest and during exercise, recording the data obtained in your own diary, contraindications after installation ECS include alcohol abuse, prolonged and exhausting physical activity, non-compliance with the work and rest regime, light physical exercise is not prohibited, since It is not only possible, but also necessary to train the heart muscle with the help of exercises, if the patient does not have severe heart failure, The presence of an pacemaker is not a contraindication for pregnancy, but the patient must be observed by a cardiac surgeon throughout the pregnancy, and delivery must be carried out by caesarean section as planned. The performance of patients is determined taking into account the nature of the work performed, the presence concomitant ischemic heart disease, chronic heart failure, and the issue of loss of ability to work is resolved collegiately with the involvement of a cardiac surgeon, cardiologist, arrhythmologist, neurologist and other specialists. A patient with pacemaker may be assigned a disability group if the working conditions are determined by a clinical expert commission as severe or could cause harm stimulator (for example, work using electric welding or electric steel-smelting machines, other sources of electromagnetic radiation).

In addition to general recommendations, the patient should always have a pacemaker passport (card) with him, and from the moment of surgery it is one of the patient’s main documents, because in case of emergency care, the doctor must be aware of the type of pacemaker and the reason why it was installed.

Despite the fact that the stimulator is equipped with a built-in protection system against electromagnetic radiation, which interferes with its electrical activity, the patient is recommended to remain at a distance of at least 15-30 cm from radiation sources– TV, cell phone, hair dryer, electric razor and other electrical appliances. It is better to talk on the phone using the hand on the opposite side to the stimulator.

MRI is also strictly contraindicated for persons with pacemaker, since such a strong magnetic field can damage the stimulator microcircuit. If necessary, MRI can be replaced by computed tomography or radiography (there is no source of magnetic radiation). For the same reason, physiotherapeutic treatment methods are strictly prohibited.

Forecast

In conclusion, I would like to note that a hundred years ago people, and especially children, often died from congenital and acquired severe heart rhythm disorders. Thanks to the achievements of modern medicine, mortality from cardiovascular diseases, including life-threatening arrhythmias, is sharply decreasing. The implantation of a pacemaker plays a significant role in this.

For example, the prognosis for complete AV block with MES attacks without surgical treatment is unfavorable, while after treatment life expectancy increases and its quality improves. That's why the patient should not be afraid of surgery to install a pacemaker, Moreover, the trauma and risk of complications are minimal, and the benefits of this device are immeasurably high.

Video: about life with a pacemaker

Step 1: pay for the consultation using the form → Step 2: after payment, ask your question in the form below ↓ Step 3: You can additionally thank the specialist with another payment for an arbitrary amount

The main types of heart pacemakers are: one-, two- and three-chamber (there are also four-chamber ones, they are often used to relieve the same diseases as three-chamber ones). According to other classifications, the following types of pacemakers are distinguished: with and without frequency adaptation function, implanted (permanent), external and temporary, asynchronous and devices synchronized with the natural heart rhythm.

Asynchronous types of pacemakers generate stimulating impulses without taking into account the electrical activity of the patient's heart. Varieties of pacemakers that stimulate the heart, taking into account the natural electrical activity of the ventricles and (or) atria, are actually R(P)-synchronized and R(P)-inhibited pacemakers. The first type of pacemaker, according to doctors, generates output signals synchronously with the work of the heart; in the absence of natural activity, such a pacemaker operates at a base frequency.

R(P)-inhibited artificial heart pacemakers (IHRs) stimulate contraction of the ventricles (atria) at a set base rate in the absence of natural electrical activity. When natural activity is detected, the IVR processor blocks the formation of the output stimulating pulse.

Types and design of pacemakers

Regardless of the type, the pacemaker design is always approximately the same:

a housing made of inert materials (as a rule, titanium or alloys based on it, the place where the electrodes are attached is covered with a plastic cover); a microprocessor that monitors a given program - can process incoming signals from sensors of physical activity, body temperature, etc. (if they are provided for by the design of a particular device); read-only memory – a storage location for the program code according to which the heart is stimulated; accumulator (battery) - an autonomous power source, designed, as a rule, for 7 - 8 years of continuous operation or more (it happens that if the pacemaker is actively working, the battery charge is consumed in 3 - 4 years); a set of sensors, at least, pulse (heart rate), although in the simplest models that can only impose the rhythm of the heart, there may not be one; electrodes - from 1 to 4 (one for each part of the heart: two atria and two ventricles) - wireless models do not have any wires (electrodes) at all.

The device determines the type of stimulator, its service life (the more functions, the faster the battery supply is consumed, for example, single-chamber R(P)-prohibited models can work for 20 years or more, and frequency-adaptive ones without a rhythm recording function can last up to 7 - 12) , work algorithm. Any type of stimulator also has a transceiver device necessary for interaction with the programmer (a mechanism for checking and adjusting the pacemaker after implantation, without surgical intervention).

Prices of different types of pacemakers

The price of different types of pacemakers ranges from 10–15 to 600–800 thousand rubles. The cost of imported ECS is higher than their domestic counterparts. The cost of different types of pacemakers varies depending on:

manufacturer - products from companies such as Biotronic (Germany) and Medtronic (USA) are more expensive than Baikal (Russia). For example, the Medtronic ECS installed for me costs 2200 - 2800 US dollars, while the domestic analogue will cost 40 - 50 thousand rubles (price for Juniors and Baikals); type - the price for such types of pacemakers as three-chamber and four-chamber is significantly higher - for imported models the cost can reach 400 - 800 thousand rubles; the presence of additional functions, for example, automatic switching of the stimulation mode, collection of extensive statistics, night mode and intracardiac electrogram recording mode.

What types of pacemakers are installed according to the quota?

All types of pacemakers are placed according to the quota, depending on the patient’s diagnosis and possible options relief of his disease. They installed Sensia SEDR01 for me, but, as they say, they usually install domestic devices according to a quota. During my time, they installed a domestic device for one man, and a foreign one for the second (like me), so the score was 2:1 not in our favor.

The conclusion that can be drawn is that they will supply what is needed (or what is available?), regardless of production. As for the types according to other classifications (by the number of electrodes, additional functions), here the choice is entirely on the side of the doctor: they choose what best relieves the patient’s disease.

What types of pacemakers are used in medicine for atrial fibrillation?

For persistent atrial fibrillation, a single-chamber or dual-chamber pacemaker is placed. Modern medicine For these purposes, it even offers wireless IVRs. In fact, atrial fibrillation remains the last disease that can be treated with single-chamber devices, and even then they are being abandoned in favor of dual-chamber models (wireless in the USA). Read more: treatment of arrhythmia with a pacemaker.

Pacemaker

In the Israeli Cardiocenter INTERCARDIO at the private clinic Herzliya Medical Center, various artificial pacemakers (APMs) and pacemakers are implanted. The heart of a person suffering from arrhythmia is not able to pump enough blood for the normal functioning of the body. This anomaly leads to constant fatigue, difficulty breathing, loss of consciousness and fainting. Over time, the disease can lead to more serious consequences. Electrocardiac pacemaker (ECS) – effective solution in cases of arrhythmia that is not amenable to drug therapy.

What is a pacemaker?

In the body of a healthy person, the rhythms of heart contraction are controlled by its own electrical impulses, which arise in a group of cells of the sinoarterial (sinus) node. A complex physiological chain leads to contraction of the atria, which pushes blood flow into the ventricles, and then into all organs and systems of the body. The combined rhythmic contractions of the atria and ventricles are called palpitations, and its disturbance is called arrhythmia. This pathological condition characterized by disturbances in the rhythm, frequency, and sequence of excitation and contraction of the heart muscles.

A small medical device, a pacemaker, helps correct many irregular heart rhythms. Low energy electrical impulses support normal cardiac activity. The pacemaker is designed to solve the following problems:

acceleration of a slow heart rate; normalization of a fast or irregular rhythm; ensuring normal contraction of the ventricles in atrial fibrillation; coordinating electrical signaling between the atria and ventricles, as well as between the ventricles; preventing arrhythmia in patients suffering from long QT syndrome (congenital or acquired).

The principle of operation of a pacemaker

A modern pacemaker is a small computer weighing up to 50 g. The device body is made of titanium, and a microcircuit and battery are placed inside. The main task of the pacemaker is to stimulate normal heart function when an abnormal (with omissions in contractions) or rare rhythm occurs. If the heartbeat occurs with the desired frequency and rhythm, the pacemaker simply monitors the heart’s own rhythm without interfering with its work.

The device's battery supplies it with electricity. The battery life is designed for 10 years; when the capacity is depleted, the ECS is replaced with a new one. Using a microcircuit inside the pacemaker, the power of electricity that is expended for the pulse is controlled. The connector block located at the top of the device serves to connect the pacemaker and electrodes. Special electrodes are fixed in the cavities of the heart and play a connecting role between the work of the pacemaker and the heart itself. It is the electrodes that transmit the impulse generated by the pacemaker to the heart and deliver data on cardiac activity to the device. Electrodes are quite flexible and durable conductors that can withstand various impacts that can be caused by both heart contractions and body movements.

Control and coordination of the activity of the pacemaker is carried out from a special computer, which is located, as a rule, in the medical institution where the devices are implanted or in advisory centers for working with patients with pacemakers. The doctor analyzes information about heart rhythms and, if necessary, changes the device settings. In addition to data on cardiac activity, the doctor can observe blood temperature, respiration and other parameters recorded by the pacemaker. Using a computer, a specialist can track cardiac events, such as ventricular fibrillation, atrial fibrillation, or supraventricular tachycardia, in chronological order.

Types of pacemakers

ECS can be permanent or temporary. To treat short-term problems (slow heartbeat due to cardiac surgery, heart attack, drug overdose), a temporary pacemaker is needed. If this device is installed, the patient remains in medical institution during the entire period of use of the device.

A permanent pacemaker is used to treat long-term problems associated with changes in heart rhythm. Today, cardiac surgery has a large number of unique models of cardiac stimulators. Each type of device is designed for a specific type of heart rhythm disorder. The need for pacemaker implantation is determined by the doctor based on the patient’s examination data.

Pacemakers used for implantation are single-chamber and multi-chamber (2 or 3 stimulating chambers). Each chamber is designed to stimulate one part of the heart. The device, which has two chambers, stimulates the right ventricle and atrium. Three-chamber devices are called cardiac resynchronization devices (CRTs). They stimulate the right atrium, left and right ventricles. CRT is used to treat particularly severe forms of heart failure.

Indications for implantation

Normal contraction of all parts of the human heart is ensured by the sinus node. This special area is located in the right atrium and is called the pacemaker. That is why the pacemaker has another name - artificial pacemaker (APM). For more than half a century, this invention has been saving the lives of hundreds of thousands of patients. Heart rhythm may change after a heart attack, with cardiosclerosis and other diseases. This pathology leads to serious disruptions in the functioning of the heart and circulatory disorders.

Implantation of IVR is prescribed for the following indications:

the presence of severe types of arrhythmias (extrasystole, atrial fibrillation, ventricular fibrillation); weakness of the sinus node; atrioventricular block (impairment or cessation of the passage of the electrical impulse between the atria and ventricles); impaired contractile function of the myocardium.

The reason for the installation of an artificial pacemaker (APM) may also be slow or suddenly stopping cardiac activity. A heart center physician may recommend IVR implantation for reasons of age, the presence of various diseases, or other factors that lead to a fast, slow, or irregular heart rhythm.

How is the operation performed?

Currently, the implantation of a pacemaker is carried out using minimally invasive heart surgery technologies. The source of the electrical impulse (battery) is placed under the skin of the patient's chest or abdomen. The electrodes are placed to the desired area of ​​the heart using a vascular probe, meaning opening the chest is not required. Medical procedures are displayed on the equipment display. To monitor the effectiveness of the procedure, heartbeats are constantly monitored. Surgery takes about an hour, the patient spends the next 24 hours in the hospital. Implantation is performed under local anesthesia.

An artificial pacemaker (APM) is a modern and reliable method of combating arrhythmia, which allows you to prevent numerous complications and lead a normal lifestyle.

In clinics, doctors are increasingly encountering patients for whom life with a pacemaker has become a common everyday problem. They do not complain about their health, continue to work in their specialty, and cope with moderate physical activity.

It is wonderful when a person who was previously bedridden due to arrhythmia attacks receives a pacemaker to get rid of the pathology.

Purpose of the device

In healthy people, contraction of the heart muscle occurs under the influence of the transmission of nerve impulses. The path runs from the sinus node in the right atrium to the interventricular septum and then by fibers diverging deeper. This ensures the correct rhythm.

The coordinated activity of the main node with the sympathetic and vagus nerves allows you to adapt the number of contractions to a specific situation: during physical work, stress, the organs and brain need more oxygen, so the heart should contract more often; during sleep, a rarer rhythm is sufficient.

Arrhythmias occur for various reasons. Electrical impulses change direction, additional foci appear, each of which “claims” to be a pacemaker.

Medicines do not always lead to successful results. There are cases when combined pathology in a person precludes the use of medications. In such a situation, installing a pacemaker comes to the rescue. He is capable of:

• “force” the heart to contract at the desired rhythm;
• suppress other sources of excitation;
• monitor a person’s own heart rhythm and intervene only in case of violations.

How does the device work?

Modern types of pacemakers can be compared to a small computer. The device weighs only 50 g. The coating is made of titanium compounds. A complex microcircuit and battery are built inside, providing autonomous power to the device. The service life of one battery is designed for 10 years. This means that the pacemaker will have to be replaced with a new one. The latest modifications of the device last from 12 to 15 years.

Durable electrodes come from the device for direct contact with the myocardium. They transmit the discharge to muscle tissue. The electrode is equipped with a special sensitive head for sufficient interaction with the heart muscle.

All materials from which the device is made are suitable for the body, do not have allergic properties, and do not deteriorate due to body movements or heart contractions.

Pacemaker operation

To understand how a pacemaker works, imagine an ordinary battery that we often use in everyday life. We always set it depending on the charge poles. In the device, a discharge occurs only when the heart’s own contractions become rare with bradycardia or chaotic with a disturbed rhythm.

The force of the discharge imposes the necessary rhythm on the heart, which is why the device is also called an artificial pacemaker. In older models, a significant drawback was the setting of a constant number of contractions, for example, 72 per minute. Of course, this is enough for a calm, measured life, slow walking. But it is not enough in cases of acceleration of movements, if you have to go for a run, or in case of excitement.

A modern heart pacemaker “does not offend”, adapts to its needs and physiological fluctuations in contraction frequency. Conductors not only transmit impulses to the myocardium, but also collect information about the established heart rhythm. The attending physician can check the effect of the device in specific situations.

Types of devices

The need for an artificial pacemaker can be temporary or permanent. Temporary installation of a pacemaker is necessary for the duration of the patient's hospital stay to treat short-term problems:

• bradycardia after heart surgery;
• eliminating drug overdose;
• relieving an attack of paroxysmal fibrillation or ventricular fibrillation.

Pacemakers for the treatment of long-term problems with arrhythmias are produced by different companies and have their own differences. Practically, they can be divided into three types.

There are no obstacles to blood outflow when installing electrodes in 2 chambers

Single-chamber - characterized by one single electrode. It is placed in the left ventricle, but it cannot influence atrial contractions; they occur independently.

Disadvantage of the model:

• in cases where the rhythm of contractions of the ventricle and atria coincides, blood circulation inside the heart chambers is disrupted;
• not applicable for atrial arrhythmias.

Double-chamber pacemaker - equipped with two electrodes, one of them is located in the ventricle, the second in the atrium cavity. Compared to single-chamber models, it has advantages because it is able to control and coordinate both atrial and ventricular rhythm changes.

Three-chamber is the most optimal model. It has three electrodes that are implanted separately into the right chambers of the heart (atrium and ventricle) and into the left ventricle. This arrangement leads to maximum approximation to the physiological path of the excitation wave, which is accompanied by the support of the correct rhythm and the necessary conditions for synchronous contraction.

Choice the desired model determined by the type of arrhythmia and the patient’s condition. The attending cardiac surgeon can always advise the patient and relatives on the optimal therapeutic effect device in a specific situation.

Why are devices coded?

For convenient use of different models without detailed descriptions of their purpose, a letter classification is used, proposed jointly by American and British scientists.

• the value of the first letter determines in which parts of the heart the electrodes are implanted (A - in the atrium, V - in the ventricle, D - in both chambers);
• the second letter reflects the camera's perception of an electrical charge;
• the third is the functions of triggering, suppressing, or both;
• fourth - indicates the presence of a mechanism for adapting contractions to physical activity;
• fifth - includes special functional activity for tachyarrhythmias.

The most common models are VVI and DDD types

When encoding, no attention is paid to the last two letters, so you have to additionally find out the functions of the device.

Indications for artificial pacemaker implantation

Persistent heart rhythm disturbances have many causes. Most often, severe heart attacks and widespread cardiosclerosis lead to failures. These changes are especially severe in old age, when the body no longer has enough strength to restore and compensate for losses.

No less often, cardiac surgeons have to deal with dangerous attacks without a clear cause (idiopathic arrhythmias).

• confidence in the weakness of the sinus node;
• the presence of such types of arrhythmias as extrasystole, paroxysmal tachycardia, atrial fibrillation, if frequent attacks of ventricular fibrillation develop;
• complete atrioventricular block with attacks of loss of consciousness;
• the need to take drugs against the background of blockade to support myocardial contractile function in cases of heart failure.

Surgery is indicated if it is not possible to cope with medication. There are no contraindications for this manipulation.

How is temporary pacing performed?

There are simplified models for temporary pacing. Depending on the location of the place where the electrodes are placed, types of stimulation are distinguished:

• endocardial,
• epicardial,
• outer,
• transesophageal.

The most effective is the endocardial option. The device is placed next to the patient, the electrode as a probe is inserted through a catheter into the subclavian vein under the control of X-ray or ultrasound equipment. When correctly installed, the electrocardiogram shows a rise in the ST interval. Bursts of energy and the ECG pattern are monitored on the monitor.

In case of external stimulation, adhesive electrodes are applied to the patient's skin. It is carried out if it is impossible to use the intracardiac method.

Epicardial installation - done with special electrodes only on an open heart during cardiac surgery

Intraesophageal stimulation is limited to temporary relief of supraventricular arrhythmias.

After the patient is removed from the dangerous state, the electrodes are removed and the heart is allowed to work at its own rhythm.

Progress of the permanent pacemaker implantation procedure

The operation to install a pacemaker for a long time is performed without opening the chest. Local anesthesia is used. Using an incision in the subclavian region, the electrodes are inserted through the subclavian vein into the heart chambers, then the device itself is sutured under the skin to the pectoral muscle.

The correct installation is checked using X-ray control and a cardiac monitor. In addition, the surgeon needs to make sure that the pacemaker is working and fully captures atrial impulses in the specified mode.

At the end, several stitches are placed on the skin and the incision site is covered with a sterile napkin.

The pacemaker is replaced after the device’s service life has expired according to the same principle as the initial installation.

How to evaluate the correct operation of a pacemaker?

The frequency of the imposed rhythm is monitored on the monitor; it must correspond to the programmed one. All artifacts (vertical bursts) must be accompanied by ventricular complexes. Insufficient frequency is possible when the battery is discharged. The contractility of the heart can be easily checked by a clear pulse in the ulnar artery.

When a natural rhythm frequency is detected that is higher than programmed, a reflex increase in the tone of the vagus nerve is used (carotid zone massage or Valsalva maneuver with straining while holding the breath).

During the operation, some actions of the medical staff are important:

• Carrying out electrocoagulation of blood vessels to stop bleeding may affect the operation of the pacemaker, therefore it is recommended to monitor the short pulse effect of the coagulator;
• anesthesiologists know a list of medications that can mask electrical impulses from the myocardium and block cardiac stimulation;
• if the patient's condition is accompanied by a violation of the concentration of potassium in the blood, the electrophysiological properties of myocardial cells are disrupted and the threshold of sensitivity to stimulation increases, this should be taken into account when selecting parameters.

How is the postoperative period going?

During the rehabilitation period after implantation of the stimulator, the patient needs to get used to slight restrictions in physical activity and movements involving muscles shoulder girdle, constant “listening” to the heart.

If the skin at the suture site is inflamed, moderate pain and fever are possible. Problems in setting up the device may be indicated by increased shortness of breath, the appearance of chest pain, and increasing weakness.

It is difficult to predict in advance how long a patient will live with the device installed. You need to use the average deadlines specified in the instructions.